As Passed by the Senate 1
123rd General Assembly 4
Regular Session Am. Sub. H. B. No. 4 5
1999-2000 6
REPRESENTATIVES GARDNER-TIBERI-BUCHY-HARRIS-BRADING-CALLENDER- 8
CAREY-CATES-CORBIN-CORE-COUGHLIN-EVANS-GOODMAN-GRENDELL- 9
HAINES-HOOD-HOOPS-JACOBSON-JOLIVETTE-KILBANE-KREBS- 10
MAIER-MEAD-METZGER-MOTTLEY-MYERS-O'BRIEN-OLMAN-PADGETT- 11
ROMAN-SALERNO-SCHULER-SCHURING-TERWILLEGER-THOMAS-WILLAMOWSKI- 12
WINKLER-WOMER BENJAMIN-YOUNG-VESPER-HOUSEHOLDER-AUSTRIA- 14
SENATORS DRAKE-KEARNS-BLESSING-JOHNSON-SPADA-CARNES-GARDNER-
OELSLAGER-RAY-WATTS-PRENTISS-DiDONATO 15
_________________________________________________________________ 17
A B I L L
To amend sections 1751.11, 1751.19, 1751.33, 19
1751.35, 1751.77, 1751.78, 1751.81, 1751.82, 21
1753.24, and 5747.01; to amend, for the purpose
of adopting new section numbers as indicated in 22
parentheses, sections 1751.83 (1751.821), 1751.84 23
(1751.822), 1751.85 (1751.823), and 1753.24
(1751.85); and to enact new sections 1751.83 and 24
1751.84 and sections 1751.811, 1751.831, 1751.87,
1751.88, 1751.89, 1753.13, 3901.80, 3901.81, 25
3901.82, 3901.83, 3901.84, 3923.65, 3923.66, 26
3923.67, 3923.68, 3923.681, 3923.69, 3923.70,
3923.75, 3923.76, 3923.77, 3923.78, and 3923.79 27
of the Revised Code to establish procedures for 29
enrollee appeals of health care coverage
decisions by health insuring corporations, 30
sickness and accident insurers, and state
employee benefit plans and to make other changes 31
in the laws related to health insuring 32
corporations, sickness and accident insurers, and
state employee benefit plans. 33
2
BE IT ENACTED BY THE GENERAL ASSEMBLY OF THE STATE OF OHIO: 35
Section 1. That sections 1751.11, 1751.19, 1751.33, 37
1751.35, 1751.77, 1751.78, 1751.81, 1751.82, 1753.24, and 5747.01 39
be amended, sections 1751.83 (1751.821), 1751.84 (1751.822), 40
1751.85 (1751.823), and 1753.24 (1751.85) be amended for the 41
purpose of adopting new section numbers as indicated in
parentheses, and new sections 1751.83 and 1751.84 and sections 42
1751.811, 1751.831, 1751.87, 1751.88, 1751.89, 1753.13, 3901.80, 43
3901.81, 3901.82, 3901.83, 3901.84, 3923.65, 3923.66, 3923.67, 44
3923.68, 3923.681, 3923.69, 3923.70, 3923.75, 3923.76, 3923.77, 45
3923.78, and 3923.79 of the Revised Code be enacted to read as 47
follows:
Sec. 1751.11. (A) Every subscriber of a health insuring 57
corporation is entitled to an evidence of coverage for the health 58
care plan under which health care benefits are provided. 60
(B) Every subscriber of a health insuring corporation that 62
offers basic health care services is entitled to an 63
identification card or similar document that specifies the health 64
insuring corporation's name as stated in its articles of 65
incorporation, and any trade or fictitious names used by the 66
health insuring corporation. The identification card or document 67
shall list at least one TOLL-FREE telephone number that provides 68
the subscriber with access to health care, TO INFORMATION on a 70
twenty-four-hours-per-day, seven-days-per-week basis, AS TO HOW 71
HEALTH CARE SERVICES MAY BE OBTAINED. THE IDENTIFICATION CARD OR 72
DOCUMENT SHALL ALSO LIST AT LEAST ONE TOLL-FREE NUMBER THAT, 73
DURING NORMAL BUSINESS HOURS, PROVIDES THE SUBSCRIBER WITH ACCESS 74
TO INFORMATION ON THE COVERAGE AVAILABLE UNDER THE SUBSCRIBER'S 75
HEALTH CARE PLAN AND INFORMATION ON THE HEALTH CARE PLAN'S 76
INTERNAL AND EXTERNAL REVIEW PROCESSES.
(C) No evidence of coverage, or amendment to the evidence 78
of coverage, shall be delivered, issued for delivery, renewed, or 79
used, until the form of the evidence of coverage or amendment has 80
been filed by the health insuring corporation with the 81
3
superintendent of insurance. If the superintendent does not 82
disapprove the evidence of coverage or amendment within sixty 83
days after it is filed it shall be deemed approved, unless the 84
superintendent sooner gives approval for the evidence of coverage 85
or amendment. With respect to an amendment to an approved 86
evidence of coverage, the superintendent only may disapprove 87
provisions amended or added to the evidence of coverage. If the 88
superintendent determines within the sixty-day period that any 89
evidence of coverage or amendment fails to meet the requirements 90
of this section, the superintendent shall so notify the health 91
insuring corporation and it shall be unlawful for the health 92
insuring corporation to use such evidence of coverage or 93
amendment. At any time, the superintendent, upon at least thirty 95
days' written notice to a health insuring corporation, may 96
withdraw an approval, deemed or actual, of any evidence of
coverage or amendment on any of the grounds stated in this 97
section. Such disapproval shall be effected by a written order, 98
which shall state the grounds for disapproval and shall be issued 100
in accordance with Chapter 119. of the Revised Code. 102
(D) No evidence of coverage or amendment shall be 104
delivered, issued for delivery, renewed, or used: 105
(1) If it contains provisions or statements that are 107
inequitable, untrue, misleading, or deceptive; 108
(2) Unless it contains a clear, concise, and complete 110
statement of the following: 111
(a) The health care services and insurance or other 114
benefits, if any, to which the AN enrollee is entitled under the 116
health care plan;
(b) Any exclusions or limitations on the health care 119
services, type of health care services, benefits, or type of 120
benefits to be provided, including copayments; 121
(c) The AN enrollee's personal financial obligation for 123
noncovered services; 125
(d) Where and in what manner general information and 128
4
information as to how HEALTH CARE services may be obtained is 130
available, including the A TOLL-FREE telephone number; 132
(e) The premium rate with respect to individual and 134
conversion contracts, and relevant copayment provisions with 135
respect to all contracts. The statement of the premium rate, 136
however, may be contained in a separate insert. 137
(f) The method utilized by the health insuring corporation 140
for resolving enrollee complaints; 141
(g) THE UTILIZATION REVIEW, INTERNAL REVIEW, AND EXTERNAL 143
REVIEW PROCEDURES ESTABLISHED UNDER SECTIONS 1751.77 TO 1751.85 145
OF THE REVISED CODE. 147
(3) Unless it provides for the continuation of an 149
enrollee's coverage, in the event that the enrollee's coverage 150
under the group policy, contract, certificate, or agreement 151
terminates while the enrollee is receiving inpatient care in a 152
hospital. This continuation of coverage shall terminate at the 153
earliest occurrence of any of the following: 154
(a) The enrollee's discharge from the hospital; 156
(b) The determination by the enrollee's attending 158
physician that inpatient care is no longer medically indicated 159
for the enrollee; however, nothing in division (D)(3)(b) of this 162
section precludes a health insuring corporation from engaging in 163
utilization review as described in the evidence of coverage. 164
(c) The enrollee's reaching the limit for contractual 166
benefits; 167
(d) The effective date of any new coverage. 170
(4) Unless it contains a provision that states, in 172
substance, that the health insuring corporation is not a member 173
of any guaranty fund, and that in the event of the health 174
insuring corporation's insolvency, the AN enrollee is protected 175
only to the extent that the hold harmless provision required by 176
section 1751.13 of the Revised Code applies to the health care 178
services rendered; 179
(5) Unless it contains a provision that states, in 181
5
substance, that in the event of the insolvency of the health 182
insuring corporation, the AN enrollee may be financially 183
responsible for health care services rendered by a provider or 184
health care facility that is not under contract to the health 185
insuring corporation, whether or not the health insuring 186
corporation authorized the use of the provider or health care 187
facility. 188
(E) Notwithstanding divisions (C) and (D) of this section, 191
a health insuring corporation may use an evidence of coverage 192
that provides for the coverage of beneficiaries enrolled in Title 194
XVIII of the "Social Security Act," 49 Stat. 620 (1935), 42 195
U.S.C.A. 301, as amended, pursuant to a medicare contract, or an 197
evidence of coverage that provides for the coverage of 198
beneficiaries enrolled in the federal employees health benefits 199
program pursuant to 5 U.S.C.A. 8905, or an evidence of coverage 201
that provides for the coverage of beneficiaries enrolled in Title 203
XIX of the "Social Security Act," 49 Stat. 620 (1935), 42 204
U.S.C.A. 301, as amended, known as the medical assistance program 206
or medicaid, provided by the Ohio department of human services 207
under Chapter 5111. of the Revised Code, or an evidence of 208
coverage that provides for the coverage of beneficiaries under 209
any other federal health care program regulated by a federal 210
regulatory body, or an evidence of coverage that provides for the 211
coverage of beneficiaries under any contract covering officers or 212
employees of the state that has been entered into by the 214
department of administrative services, if both of the following 216
apply: 217
(1) The evidence of coverage has been approved by the 219
United States department of health and human services, the United 221
States office of personnel management, the Ohio department of 222
human services, or the department of administrative services. 223
(2) The evidence of coverage is filed with the 225
superintendent of insurance prior to use and is accompanied by 226
documentation of approval from the United States department of 228
6
health and human services, the United States office of personnel 229
management, the Ohio department of human services, or the 230
department of administrative services. 231
Sec. 1751.19. (A) A health insuring corporation shall 241
establish and maintain a complaint system that has been approved 242
by the superintendent of insurance to provide adequate and 243
reasonable procedures for the expeditious resolution of written 244
complaints initiated by subscribers or enrollees concerning any 245
matter relating to services provided, directly or indirectly, by 246
the health insuring corporation, including, but not limited to, 247
claims COMPLAINTS regarding the scope of coverage for health care 248
services, and denials, cancellations, or nonrenewals of coverage. 250
COMPLAINTS REGARDING A HEALTH INSURING CORPORATION'S DECISION TO 252
DENY, REDUCE, OR TERMINATE COVERAGE FOR HEALTH CARE SERVICES ARE
SUBJECT TO SECTION 1751.83 OF THE REVISED CODE. 253
(B) A health insuring corporation shall provide a timely 256
written response to each written complaint it receives. 257
Responses to written complaints relating to quality or 258
appropriateness of care shall set forth a statement informing the 259
complainant in detail of any rights the complainant may have to 260
submit such complaint to any professional peer review 261
organization or health insuring corporation peer review committee 262
that has been set up to monitor the quality or appropriateness of 263
provider services rendered. Such statement shall set forth the 264
name of the peer review organization or health insuring 265
corporation peer review committee, its address, telephone number, 266
and any other pertinent data that will enable the complainant to 267
seek further independent review of the complaint. Such appeal 268
shall not be made to the peer review corporation or health 269
insuring corporation peer review committee until the complaint 270
system of the health insuring corporation has been exhausted. 271
(C) Copies of complaints and responses, including medical 274
records related to those complaints, shall be available to the 275
superintendent and the director of health for inspection for 276
7
three years. Any document or information provided to the 277
superintendent pursuant to this division that contains a medical 278
record is confidential, and is not a public record subject to 279
section 149.43 of the Revised Code.
(D) A health insuring corporation shall establish and 282
maintain a procedure to accept complaints over the telephone or 283
in person. These complaints are not subject to the reporting 284
requirement under division (C) of section 1751.32 of the Revised 286
Code.
(E) A HEALTH INSURING CORPORATION MAY COMPLY WITH THIS 289
SECTION AND SECTION 1751.83 OF THE REVISED CODE BY ESTABLISHING 290
ONE SYSTEM FOR RECEIVING AND REVIEWING COMPLAINTS AND REQUESTS 291
FOR INTERNAL REVIEW FROM ENROLLEES AND SUBSCRIBERS IF THE SYSTEM
MEETS THE REQUIREMENTS OF BOTH SECTIONS. 293
Sec. 1751.33. (A) Each health insuring corporation shall 302
provide to its subscribers, by mail, a description of the health 303
insuring corporation, its method of operation, its service area, 304
its most recent provider list, and its complaint procedure 305
established pursuant to section 1751.19 of the Revised Code, AND 307
A DESCRIPTION OF ITS UTILIZATION REVIEW, INTERNAL REVIEW, AND 308
EXTERNAL REVIEW PROCESSES ESTABLISHED UNDER SECTIONS 1751.77 TO 309
1751.85 OF THE REVISED CODE. AT THE REQUEST OF OR WITH THE 310
APPROVAL OF THE SUBSCRIBER, A HEALTH INSURING CORPORATION MAY 312
PROVIDE THIS INFORMATION BY ELECTRONIC MEANS RATHER THAN BY MAIL. 313
A health insuring corporation providing basic health care 315
services or supplemental health care services shall provide this 316
information annually. A health insuring corporation providing
only specialty health care services shall provide this 317
information biennially.
(B) Each health insuring corporation, upon the request of 320
a subscriber, shall make available its most recent statutory 321
financial statement.
Sec. 1751.35. (A) The superintendent of insurance may 331
suspend or revoke any certificate of authority issued to a health 332
8
insuring corporation under this chapter if the superintendent 333
finds that:
(1) The health insuring corporation is operating in 335
contravention of its articles of incorporation, its health care 336
plan or plans, or in a manner contrary to that described in and 337
reasonably inferred from any other information submitted under 338
section 1751.03 of the Revised Code, unless amendments to such 340
submissions have been filed and have taken effect in compliance 341
with this chapter. 342
(2) The health insuring corporation fails to issue 344
evidences of coverage in compliance with the requirements of 345
section 1751.11 of the Revised Code. 347
(3) The contractual periodic prepayments or premium rates 349
used do not comply with the requirements of section 1751.12 of 350
the Revised Code. 351
(4) The health insuring corporation enters into a 353
contract, agreement, or other arrangement with any health care 354
facility or provider, that does not comply with the requirements 355
of section 1751.13 of the Revised Code, or the corporation fails 357
to provide an annual certificate as required by section 1751.13 358
of the Revised Code. 360
(5) The director of health has certified, after a hearing 362
conducted in accordance with Chapter 119. of the Revised Code, 364
that the health insuring corporation no longer meets the 365
requirements of section 1751.04 of the Revised Code. 367
(6) The health insuring corporation is no longer 369
financially responsible and may reasonably be expected to be 370
unable to meet its obligations to enrollees or prospective 371
enrollees. 372
(7) The health insuring corporation has failed to 374
implement the complaint system that complies with the 375
requirements of section 1751.19 of the Revised Code. 378
(8) The health insuring corporation, or any agent or 380
representative of the corporation, has advertised, merchandised, 381
9
or solicited on its behalf in contravention of the requirements 382
of section 1751.31 of the Revised Code. 383
(9) The health insuring corporation has unlawfully 385
discriminated against any enrollee or prospective enrollee with 386
respect to enrollment, disenrollment, or price or quality of 387
health care services. 388
(10) The continued operation of the health insuring 390
corporation would be hazardous or otherwise detrimental to its 391
enrollees. 392
(11) The health insuring corporation has submitted false 394
information in any filing or submission required under this 395
chapter or any rule adopted under this chapter. 396
(12) The health insuring corporation has otherwise failed 398
to substantially comply with this chapter or any rule adopted 399
under this chapter. 400
(13) The health insuring corporation is not operating a 402
health care plan. 403
(14) THE HEALTH INSURING CORPORATION HAS FAILED TO COMPLY 405
WITH ANY OF THE REQUIREMENTS OF SECTIONS 1751.77 TO 1751.88 OF 406
THE REVISED CODE.
(B) A certificate of authority shall be suspended or 409
revoked only after compliance with the requirements of Chapter 410
119. of the Revised Code. 411
(C) When the certificate of authority of a health insuring 414
corporation is suspended, the health insuring corporation, during 415
the period of suspension, shall not enroll any additional 416
subscribers or enrollees except newborn children or other newly 417
acquired dependents of existing subscribers or enrollees, and 418
shall not engage in any advertising or solicitation whatsoever. 419
(D) When the certificate of authority of a health insuring 422
corporation is revoked, the health insuring corporation, 423
following the effective date of the order of revocation, shall 424
conduct no further business except as may be essential to the 425
orderly conclusion of the affairs of the health insuring 426
10
corporation. The health insuring corporation shall engage in no 427
further advertising or solicitation whatsoever. The 428
superintendent, by written order, may permit such further 429
operation of the health insuring corporation as the 430
superintendent may find to be in the best interest of enrollees, 431
to the end that enrollees will be afforded the greatest practical 432
opportunity to obtain continuing health care coverage. 433
Sec. 1751.77. As used in sections 1751.77 to 1751.86 442
1751.88 of the Revised Code, unless otherwise specifically 444
provided:
(A) "Adverse determination" means a determination by a 446
health insuring corporation or its designee utilization review 447
organization that an admission, availability of care, continued 449
stay, or other health care service covered under a policy, 450
contract, or agreement of the health insuring corporation has 452
been reviewed and, based upon the information provided, the 453
health care service does not meet the health insuring 455
corporation's requirements for benefit payment UNDER THE HEALTH 456
INSURING CORPORATION'S POLICY, CONTRACT, OR AGREEMENT, and
COVERAGE is therefore denied, reduced, or terminated. 458
(B) "Ambulatory review" means utilization review of health 460
care services performed or provided in an outpatient setting. 461
(C) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 463
PERSON AUTHORIZED TO ACT ON BEHALF OF AN ENROLLEE WITH RESPECT TO 464
HEALTH CARE DECISIONS. 465
(D) "Case management" means a coordinated set of 467
activities conducted for individual patient management of 468
serious, complicated, protracted, or other specified health 469
conditions.
(D)(E) "Certification" means a determination by a health 471
insuring corporation or its designee utilization review 474
organization that an admission, availability of care, continued 475
stay, or other health care service covered under a policy, 476
contract, or agreement of the health insuring corporation has 478
11
been reviewed and, based upon the information provided, the 479
health care service satisfies the health insuring corporation's 480
requirements for benefit payment UNDER THE HEALTH INSURING 481
CORPORATION'S POLICY, CONTRACT, OR AGREEMENT. 482
(E)(F) "Clinical peer" means a physician when an 485
evaluation is to be made of the clinical appropriateness of 486
health care services provided by a physician. If an evaluation 487
is to be made of the clinical appropriateness of health care 488
services provided by a provider who is not a physician, "clinical 489
peer" means either a physician or a provider holding the same 490
license as the provider who provided the health care services. 491
(F)(G) "Clinical review criteria" means the written 493
screening procedures, decision abstracts, clinical protocols, and 494
practice guidelines used by a health insuring corporation to 495
determine the necessity and appropriateness of health care 497
services.
(G)(H) "Concurrent review" means utilization review 499
conducted during a patient's hospital stay or course of 500
treatment.
(H)(I) "Discharge planning" means the formal process for 502
determining, prior to a patient's discharge from a health care 503
facility, the coordination and management of the care that the 505
patient is to receive following discharge from a health care 506
facility.
(I)(J) "Participating provider" means a provider or health 508
care facility that, under a contract with a health insuring 510
corporation or with its contractor or subcontractor, has agreed 512
to provide health care services to enrollees with an expectation
of receiving payment, other than coinsurance, copayments, or 513
deductibles, directly or indirectly from the health insuring 514
corporation.
(J)(K) "Physician" means a provider authorized WHO HOLDS A 517
CERTIFICATE ISSUED under chapter CHAPTER 4731. of the Revised 519
Code to AUTHORIZING THE practice OF medicine and surgery or 521
12
osteopathic medicine and surgery OR A COMPARABLE LICENSE OR
CERTIFICATE FROM ANOTHER STATE. 522
(K)(L) "Prospective review" means utilization review that 524
is conducted prior to an admission or a course of treatment. 525
(L)(M) "Retrospective review" means utilization review of 527
medical necessity that is conducted after health care services 529
have been provided to a patient. "Retrospective review" does not 531
include the review of a claim that is limited to an evaluation of 532
reimbursement levels, veracity of documentation, accuracy of 533
coding, or adjudication of payment.
(M)(N) "Second opinion" means an opportunity or 535
requirement to obtain a clinical evaluation by a provider other 537
than the provider originally making a recommendation for proposed 538
health care services to assess the clinical necessity and 539
appropriateness of the proposed health care services. 540
(N)(O) "Utilization review" means a process used to 542
monitor the use of, or evaluate the clinical necessity, 544
appropriateness, efficacy, or efficiency of, health care 545
services, procedures, or settings. Areas of review may include 546
ambulatory review, prospective review, second opinion,
certification, concurrent review, case management, discharge 547
planning, or retrospective review. 548
(O)(P) "Utilization review organization" means an entity 550
that conducts utilization review, other than a health insuring 551
corporation performing a review of its own health care plans. 553
Sec. 1751.78. (A)(1) Sections 1751.77 to 1751.86 1751.88 563
of the Revised Code apply to any health insuring corporation that 565
provides or performs utilization review services in connection 566
with its policies, contracts, and agreements providing COVERING 567
basic health care services and to any designee of the health 568
insuring corporation, or to any utilization review organization 571
that performs utilization review functions on behalf of the 572
health insuring corporation in connection with policies,
contracts, or agreements of the health insuring corporation 573
13
providing COVERING basic health care services. 575
(2) Nothing in sections 1751.77 to 1751.82 or section 577
1751.85 1751.823 of the Revised Code shall be construed to 578
require a health insuring corporation to provide or perform 579
utilization review services in connection with health care 580
services provided under a policy, plan, or agreement of 581
supplemental health care services or specialty health care 582
services. 583
(B)(1) Each health insuring corporation shall be 586
responsible for monitoring all utilization review AND INTERNAL 587
REVIEW activities carried out by, or on behalf of, the health 589
insuring corporation and for ensuring that all requirements of 590
sections 1751.77 to 1751.86 1751.88 of the Revised Code, and any 591
rules adopted thereunder, are met. The health insuring 593
corporation shall also ensure that appropriate personnel have 594
operational responsibility for the conduct of the health insuring 595
corporation's utilization review program. 596
(2) If a health insuring corporation contracts to have a 598
utilization review organization or other entity perform the 599
utilization review functions required by sections 1751.77 to 600
1751.86 1751.88 of the Revised Code, and any rules adopted 602
thereunder, the superintendent of insurance shall hold the health 604
insuring corporation responsible for monitoring the activities of
the utilization review organization or other entity and for 605
ensuring that the requirements of those sections and rules are 606
met. 607
Sec. 1751.81. (A) As used in this section: 616
(1) "Enrollee" includes the representative of an enrollee. 618
(2) "Necessary, "NECESSARY information" includes the 621
results of any face-to-face clinical evaluation or second opinion 624
that may be required.
(B) A health insuring corporation shall maintain written 626
procedures for DETERMINING WHETHER A REQUESTED SERVICE IS A 627
SERVICE COVERED UNDER THE TERMS OF AN ENROLLEE'S POLICY, 628
14
CONTRACT, OR AGREEMENT, making utilization review determinations, 630
and for notifying enrollees, and participating providers, and 631
health care facilities acting on behalf of enrollees, of its 633
determinations.
(C) For initial PROSPECTIVE REVIEW determinations, a 636
health insuring corporation shall make the determination within 638
two business days after obtaining all necessary information 639
regarding a proposed admission, procedure, or health care service 640
requiring a review determination. 642
(1) In the case of a determination to certify an 644
admission, procedure, or health care service, the health insuring 645
corporation shall notify the provider or health care facility 646
rendering the health care service by telephone or facsimile 647
within three business days after making the initial 648
certification.
(2) In the case of an adverse determination, the health 650
insuring corporation shall notify the provider or health care 652
facility rendering the health care service by telephone within 653
three business days after making the adverse determination, and 654
shall provide written or electronic confirmation of the telephone 655
notification to the enrollee and the provider or health care 656
facility within one business day after making the telephone 657
notification.
(D) For concurrent review determinations, a health 659
insuring corporation shall make the determination within one 662
business day after obtaining all necessary information. 663
(1) In the case of a determination to certify an extended 665
stay or additional health care services, the health insuring 666
corporation shall notify the provider or health care facility 667
rendering the health care service by telephone or facsimile 668
within one business day after making the certification. 670
(2) In the case of an adverse determination, the health 672
insuring corporation shall notify the provider or health care 673
facility rendering the health care service by telephone within 674
15
one business day after making the adverse determination, and 675
shall provide written or electronic confirmation to the enrollee 676
and the provider or health care facility within one business day 677
after the telephone notification. The health care service to the 678
enrollee shall be continued, with standard copayments and 680
deductibles, if applicable, until the enrollee has been notified 681
of the determination. 682
(E) For retrospective review determinations, a health 684
insuring corporation shall make the determination within thirty 688
business days after receiving all necessary information. 689
(1) In the case of a certification, the health insuring 691
corporation may notify the enrollee and the provider or health 693
care facility rendering the health care service in writing. 694
(2) In the case of an adverse determination, the health 696
insuring corporation shall notify the enrollee and the provider 698
or health care facility rendering the health care service, in 699
writing, within five business days after making the adverse 700
determination.
(F)(1) The time frames set forth in divisions (C), (D), 703
and (E) of this section for determinations and notifications 705
shall prevail unless the seriousness of the medical condition of
the enrollee otherwise requires a more timely response from the 706
health insuring corporation. The health insuring corporation 707
shall maintain written procedures for making expedited 709
utilization review determinations and notifications of enrollees 710
and providers or health care facilities when warranted by the 711
medical condition of the enrollee. 712
(2) AN ENROLLEE, AN AUTHORIZED PERSON, THE ENROLLEE'S 714
PROVIDER, OR THE HEALTH CARE FACILITY RENDERING HEALTH CARE 715
SERVICE TO AN ENROLLEE MAY PROCEED WITH A REQUEST FOR AN INTERNAL 717
REVIEW PURSUANT TO SECTION 1751.83 OF THE REVISED CODE IF A 720
HEALTH INSURING CORPORATION FAILS TO MAKE A DETERMINATION AND 721
NOTIFICATION WITHIN THE TIME FRAMES SET FORTH IN DIVISION (C), 723
(D), OR (E) OF THIS SECTION. THE ENROLLEE MAY REQUEST A REVIEW 725
16
WITHOUT THE APPROVAL OF THE PROVIDER OR THE HEALTH CARE FACILITY 726
RENDERING THE HEALTH CARE SERVICE. THE PROVIDER OR HEALTH CARE 727
FACILITY MAY NOT REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF 728
THE ENROLLEE.
THE HEALTH INSURING CORPORATION'S FAILURE TO MAKE A 731
DETERMINATION AND NOTIFICATION WITHIN THE TIME FRAMES SET FORTH 732
IN DIVISION (C), (D), OR (E) OF THIS SECTION SHALL BE DEEMED TO 733
BE AN ADVERSE DETERMINATION BY THE HEALTH INSURING CORPORATION 734
FOR THE PURPOSE OF INITIATING AN INTERNAL REVIEW. 735
(G) A written notification of an adverse determination 737
shall include the principal reason or reasons for the 738
determination, instructions for initiating an appeal or A 740
reconsideration of the determination UNDER SECTION 1751.82 OF THE 741
REVISED CODE OR AN INTERNAL REVIEW UNDER SECTION 1751.83 OF THE 743
REVISED CODE, and instructions for requesting a written statement 744
of the clinical rationale used to make the determination. A 745
health insuring corporation shall provide the clinical rationale 747
for an adverse determination in writing to any party who received 748
notice of the adverse determination and who follows the 749
instructions for a request. 750
(H)(1) A health insuring corporation shall have written 752
procedures to address the failure or inability of a health care 754
facility, provider, or enrollee to provide all necessary 755
information for review.
(2) A HEALTH INSURING CORPORATION SHALL NOT USE 757
UNREASONABLE REQUESTS FOR INFORMATION TO DELAY MAKING A 758
DETERMINATION. 759
(3) If the health care facility, provider, or enrollee 762
will not release necessary information, the health insuring 763
corporation may deny certification. AN ENROLLEE NEED NOT BE 764
GRANTED AN INTERNAL REVIEW PURSUANT TO SECTION 1751.83 OF THE 765
REVISED CODE BASED ON A HEALTH INSURING CORPORATION'S FAILURE TO 767
MAKE A TIMELY DETERMINATION, IF THE HEALTH INSURING CORPORATION'S 768
DELAY IN MAKING A DETERMINATION AND NOTIFICATION IS CAUSED BY THE 769
17
FAILURE OF A HEALTH CARE FACILITY, PROVIDER, OR ENROLLEE TO 770
RELEASE ALL NECESSARY INFORMATION, IN WHICH CASE THE HEALTH 771
INSURING CORPORATION SHALL NOTIFY THE ENROLLEE IN WRITING OF THE 772
REASON FOR THE DELAY.
Sec. 1751.811. IN LIEU OF CONDUCTING A PROSPECTIVE, 774
CONCURRENT, OR RETROSPECTIVE REVIEW UNDER SECTION 1751.81 OF THE 775
REVISED CODE, PROVIDING A RECONSIDERATION UNDER SECTION 1751.82 777
OF THE REVISED CODE, OR CONDUCTING AN INTERNAL REVIEW UNDER 779
SECTION 1751.83 OF THE REVISED CODE, A HEALTH INSURING 780
CORPORATION MAY AFFORD AN ENROLLEE AN OPPORTUNITY FOR AN EXTERNAL 781
REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE REVISED CODE. IF 782
AN EXTERNAL REVIEW IS CONDUCTED PURSUANT TO THIS SECTION, THE 783
HEALTH INSURING CORPORATION IS NOT REQUIRED TO AFFORD THE 785
ENROLLEE AN OPPORTUNITY FOR ANY OF THE REVIEWS THAT WERE
DISREGARDED PURSUANT TO THIS SECTION, INCLUDING THE EXTERNAL 787
REVIEW THAT MAY HAVE RESULTED FROM A REVIEW THAT WAS DISREGARDED 788
PURSUANT TO THIS SECTION, UNLESS NEW CLINICAL INFORMATION IS 789
SUBMITTED TO THE HEALTH INSURING CORPORATION. 790
Sec. 1751.82. (A) In a case involving an initial A 800
PROSPECTIVE determination or a concurrent review determination, a 802
health insuring corporation shall give the provider or health
care facility rendering the health care service an opportunity to 804
request in writing on behalf of the enrollee a reconsideration of 805
an adverse determination by the reviewer making the adverse 806
determination. THE PROVIDER OR HEALTH CARE FACILITY MAY NOT 807
REQUEST A RECONSIDERATION WITHOUT THE PRIOR CONSENT OF THE 808
ENROLLEE. The reconsideration shall occur within three business 809
days after the health insuring corporation's receipt of the 810
written request for reconsideration, and shall be conducted 811
between the provider or health care facility rendering the health 812
care service and the reviewer who made the adverse determination. 814
If that reviewer cannot be available within three business days, 815
the reviewer may designate another reviewer.
(B) If the reconsideration process described in division 817
18
(A) of this section does not resolve the difference of opinion, 819
the adverse determination may be appealed by the enrollee, AN 820
AUTHORIZED PERSON, or the provider or health care facility ACTING 821
on behalf of the enrollee MAY REQUEST AN INTERNAL REVIEW UNDER 822
SECTION 1751.83 OF THE REVISED CODE. THE PROVIDER OR HEALTH CARE 823
FACILITY MAY NOT REQUEST AN INTERNAL REVIEW WITHOUT THE PRIOR 824
CONSENT OF THE ENROLLEE.
(C) Reconsideration is not a prerequisite to a standard AN 825
INTERNAL or expedited appeal EXTERNAL REVIEW of an adverse 827
determination.
(D) The time period allowed by division (A) of this 830
section for a reconsideration of an adverse determination shall 831
not apply if the seriousness of the medical condition of the 832
enrollee requires a more expedited reconsideration. The health 833
insuring corporation shall maintain written procedures for making 834
such an expedited reconsideration. 835
Sec. 1751.83 1751.821. A health insuring corporation may 845
present evidence of compliance with the requirements of sections 846
1751.77 to 1751.82 of the Revised Code by submitting evidence to 848
the superintendent of insurance of its accreditation by an
independent, private accrediting organization, such as the 849
national committee on quality assurance, the national quality 850
health council, the joint commission on accreditation of health 852
care organizations, or the American accreditation healthcare
commission/utilization review accreditation commission. The 854
superintendent, upon review of the organization's accreditation 855
process, may determine that such accreditation constitutes 856
compliance by the health insuring corporation with the 857
requirements of these sections.
Sec. 1751.84 1751.822. Each participating provider or 866
health care facility submitting a claim shall cooperate with the 868
utilization review program of a health insuring corporation or 869
utilization review organization and shall provide the health 870
insuring corporation or its designee access to an enrollee's 871
19
medical records during regular business hours, or copies of those 872
records at a reasonable cost. 873
Sec. 1751.85 1751.823. A health insuring corporation shall 882
annually file a certificate with the superintendent of insurance 884
certifying its compliance with sections 1751.77 to 1751.82 of the 885
Revised Code. 887
Sec. 1751.83. A HEALTH INSURING CORPORATION SHALL 889
ESTABLISH AND MAINTAIN AN INTERNAL REVIEW SYSTEM THAT HAS BEEN 890
APPROVED BY THE SUPERINTENDENT OF INSURANCE. THE SYSTEM SHALL 891
PROVIDE FOR REVIEW BY A CLINICAL PEER AND INCLUDE ADEQUATE AND 892
REASONABLE PROCEDURES FOR REVIEW AND RESOLUTION OF APPEALS FROM
ENROLLEES CONCERNING ADVERSE DETERMINATIONS MADE UNDER SECTION 895
1751.81 OF THE REVISED CODE, INCLUDING PROCEDURES FOR VERIFYING 896
AND REVIEWING APPEALS FROM ENROLLEES WHOSE MEDICAL CONDITIONS
REQUIRE EXPEDITED REVIEW. 897
A HEALTH INSURING CORPORATION SHALL CONSIDER AND PROVIDE A 899
WRITTEN RESPONSE TO EACH REQUEST FOR AN INTERNAL REVIEW NOT LATER 901
THAN SIXTY DAYS AFTER RECEIPT OF THE REQUEST, EXCEPT THAT IF THE 902
SERIOUSNESS OF THE ENROLLEE'S MEDICAL CONDITION REQUIRES AN 903
EXPEDITED REVIEW, THE HEALTH INSURING CORPORATION SHALL PROVIDE 904
THE WRITTEN RESPONSE NOT LATER THAN SEVEN DAYS AFTER RECEIPT OF 905
THE REQUEST. THE RESPONSE SHALL STATE THE REASON FOR THE HEALTH 909
INSURING CORPORATION'S DECISION, INFORM THE ENROLLEE OF THE RIGHT
TO PURSUE A FURTHER REVIEW, AND EXPLAIN THE PROCEDURES FOR 911
INITIATING THE REVIEW, INCLUDING THE TIME FRAMES WITHIN WHICH THE 912
ENROLLEE MUST REQUEST THE REVIEW, AS SPECIFIED IN SECTION 1751.84 913
OR 1751.85 OF THE REVISED CODE. FAILURE BY A HEALTH INSURING 914
CORPORATION TO PROVIDE A WRITTEN RESPONSE WITHIN THE TIME FRAMES 915
SPECIFIED UNDER THIS SECTION SHALL BE DEEMED A DENIAL BY THE 916
HEALTH INSURING CORPORATION FOR PURPOSES OF REQUESTING A REVIEW 917
UNDER SECTION 1751.831, 1751.84, OR 1751.85 OF THE REVISED CODE. 918
IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 922
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 923
THE SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 924
20
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, THE RESPONSE SHALL 925
INFORM THE ENROLLEE OF THE RIGHT TO REQUEST A REVIEW BY THE 926
SUPERINTENDENT OF INSURANCE UNDER SECTION 1751.831 OF THE REVISED 927
CODE. IF THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, OR 928
TERMINATED COVERAGE FOR A HEALTH CARE SERVICE ON THE GROUNDS THAT 929
THE SERVICE IS NOT MEDICALLY NECESSARY, THE RESPONSE SHALL INFORM 931
THE ENROLLEE OF THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER 932
SECTION 1751.84 OF THE REVISED CODE, EXCEPT THAT IF THE ENROLLEE 934
MEETS THE CRITERIA SET FORTH IN DIVISION (A) OF SECTION 1751.85 935
OF THE REVISED CODE, THE RESPONSE SHALL INFORM THE ENROLLEE OF 936
THE RIGHT TO REQUEST AN EXTERNAL REVIEW UNDER SECTION 1751.85 OF 937
THE REVISED CODE.
THE HEALTH INSURING CORPORATION SHALL MAKE AVAILABLE TO THE 939
SUPERINTENDENT FOR INSPECTION COPIES OF ALL DOCUMENTS IN THE 940
HEALTH INSURING CORPORATION'S POSSESSION RELATED TO REVIEWS 941
CONDUCTED PURSUANT TO THIS SECTION, INCLUDING MEDICAL RECORDS 942
RELATED TO THOSE REVIEWS, AND OF RESPONSES, FOR THREE YEARS 943
FOLLOWING COMPLETION OF THE REVIEW. 944
Sec. 1751.831. THE SUPERINTENDENT OF INSURANCE SHALL 946
ESTABLISH AND MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING 947
REQUESTS FOR REVIEW FROM OR ON BEHALF OF ENROLLEES WHO, UNDER 948
SECTION 1751.83 OF THE REVISED CODE, HAVE BEEN DENIED COVERAGE OF 949
A HEALTH CARE SERVICE OR HAD COVERAGE REDUCED OR TERMINATED WHEN 950
THE GROUNDS FOR THE DENIAL, REDUCTION, OR TERMINATION IS THAT THE 951
SERVICE IS NOT A SERVICE COVERED UNDER THE TERMS OF THE 952
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT. 953
ON RECEIPT OF A WRITTEN REQUEST FROM AN ENROLLEE OR 955
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 956
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 958
ENROLLEE'S POLICY, CONTRACT, OR AGREEMENT, EXCEPT THAT THE 959
SUPERINTENDENT SHALL NOT CONDUCT A REVIEW UNDER THIS SECTION 960
UNLESS THE ENROLLEE HAS EXHAUSTED THE HEALTH INSURING 961
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO
SECTION 1751.83 OF THE REVISED CODE. THE HEALTH INSURING 962
21
CORPORATION AND THE ENROLLEE OR AUTHORIZED PERSON SHALL PROVIDE 963
THE SUPERINTENDENT WITH ANY INFORMATION REQUIRED BY THE 964
SUPERINTENDENT THAT IS IN THEIR POSSESSION AND IS GERMANE TO THE 965
REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 967
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 968
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 969
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 970
ENROLLEE'S CONTRACT, POLICY, OR AGREEMENT. THE SUPERINTENDENT 971
SHALL NOTIFY THE ENROLLEE AND THE HEALTH INSURING CORPORATION OF 972
THE SUPERINTENDENT'S DETERMINATION OR THAT THE SUPERINTENDENT IS 973
NOT ABLE TO MAKE A DETERMINATION. 974
IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 976
CORPORATION THAT MAKING THE DETERMINATION REQUIRES THE RESOLUTION 977
OF A MEDICAL ISSUE, THE HEALTH INSURING CORPORATION SHALL AFFORD 978
THE ENROLLEE AN OPPORTUNITY FOR EXTERNAL REVIEW UNDER SECTION 979
1751.84 OR 1751.85 OF THE REVISED CODE. IF THE SUPERINTENDENT 980
NOTIFIES THE HEALTH INSURING CORPORATION THAT THE HEALTH SERVICE 981
IS A COVERED SERVICE, THE HEALTH INSURING CORPORATION SHALL 982
EITHER COVER THE SERVICE OR AFFORD THE ENROLLEE AN OPPORTUNITY
FOR AN EXTERNAL REVIEW UNDER SECTION 1751.84 OR 1751.85 OF THE 983
REVISED CODE. IF THE SUPERINTENDENT NOTIFIES THE HEALTH INSURING 984
CORPORATION THAT THE HEALTH CARE SERVICE IS NOT A COVERED 985
SERVICE, THE HEALTH INSURING CORPORATION IS NOT REQUIRED TO COVER 986
THE SERVICE OR AFFORD THE ENROLLEE AN EXTERNAL REVIEW. 987
Sec. 1751.84. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 990
(C) OF THIS SECTION, A HEALTH INSURING CORPORATION SHALL AFFORD 992
AN ENROLLEE AN OPPORTUNITY FOR AN EXTERNAL REVIEW IF BOTH OF THE 993
FOLLOWING ARE THE CASE:
(1) THE HEALTH INSURING CORPORATION HAS DENIED, REDUCED, 995
OR TERMINATED COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE 998
SERVICE EXCEPT FOR THE FACT THAT THE HEALTH INSURING CORPORATION 999
HAS DETERMINED THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY 1,000
NECESSARY;
22
(2) EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, THE 1,002
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 1,004
COST THE ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED
SERVICE IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 1,005
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 1,007
SECTION, EXCEPT THAT IF AN ENROLLEE WITH A TERMINAL CONDITION 1,008
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 1751.85 OF 1,009
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 1,011
THAT SECTION.
(B) AN ENROLLEE NEED NOT BE AFFORDED A REVIEW UNDER THIS 1,013
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 1,014
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 1,016
SECTION 1751.831 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 1,018
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE ENROLLEE'S 1,019
POLICY, CONTRACT, OR AGREEMENT. 1,020
(2) EXCEPT AS PROVIDED IN SECTION 1751.811 OF THE REVISED 1,022
CODE, THE ENROLLEE HAS FAILED TO EXHAUST THE HEALTH INSURING 1,023
CORPORATION'S INTERNAL REVIEW PROCESS ESTABLISHED PURSUANT TO 1,024
SECTION 1751.83 OF THE REVISED CODE. 1,025
(3) THE ENROLLEE HAS PREVIOUSLY BEEN AFFORDED AN EXTERNAL 1,027
REVIEW FOR THE SAME ADVERSE DETERMINATION AND NO NEW CLINICAL 1,028
INFORMATION HAS BEEN SUBMITTED TO THE HEALTH INSURING 1,029
CORPORATION.
(C)(1) A HEALTH INSURING CORPORATION MAY DENY A REQUEST 1,031
FOR AN EXTERNAL REVIEW OF AN ADVERSE DETERMINATION IF IT IS 1,033
REQUESTED LATER THAN SIXTY DAYS AFTER THE ENROLLEE'S RECEIPT OF 1,034
NOTICE OF THE RESULT OF AN INTERNAL REVIEW BROUGHT UNDER SECTION 1,036
1751.83 OF THE REVISED CODE. AN EXTERNAL REVIEW MAY BE REQUESTED 1,038
BY THE ENROLLEE, AN AUTHORIZED PERSON, THE ENROLLEE'S PROVIDER, 1,040
OR A HEALTH CARE FACILITY RENDERING HEALTH CARE SERVICE TO THE 1,041
ENROLLEE. THE ENROLLEE MAY REQUEST A REVIEW WITHOUT THE APPROVAL 1,042
OF THE PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE HEALTH 1,043
CARE SERVICE. THE PROVIDER OR HEALTH CARE FACILITY MAY NOT 1,044
REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF THE ENROLLEE. 1,045
23
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 1,047
EXCEPT THAT IF THE ENROLLEE HAS A CONDITION THAT REQUIRES 1,048
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 1,049
ELECTRONIC MEANS. WHEN AN ORAL OR ELECTRONIC REQUEST FOR REVIEW 1,050
IS MADE, WRITTEN CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED 1,052
TO THE HEALTH INSURING CORPORATION NOT LATER THAN FIVE DAYS AFTER 1,053
THE ORAL OR WRITTEN REQUEST IS SUBMITTED. 1,054
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 1,056
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 1,058
THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE 1,059
HEALTH CARE SERVICE TO THE ENROLLEE THAT THE PROPOSED SERVICE,
PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL COST THE 1,060
ENROLLEE MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED SERVICE 1,061
IS NOT COVERED BY THE HEALTH INSURING CORPORATION. 1,062
(3) FOR AN EXPEDITED REVIEW, THE ENROLLEE'S PROVIDER MUST 1,064
CERTIFY THAT THE ENROLLEE'S CONDITION COULD, IN THE ABSENCE OF 1,065
IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE FOLLOWING: 1,067
(a) PLACING THE HEALTH OF THE ENROLLEE OR, WITH RESPECT TO 1,069
A PREGNANT WOMAN, THE HEALTH OF THE ENROLLEE OR THE UNBORN CHILD, 1,070
IN SERIOUS JEOPARDY; 1,071
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 1,073
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 1,075
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 1,077
OF AN ADVERSE DETERMINATION SHALL INCLUDE ALL OF THE FOLLOWING: 1,078
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 1,080
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 1,081
SECTION 3901.80 OF THE REVISED CODE. 1,082
(2) EXCEPT AS PROVIDED IN DIVISION (D)(3) AND (4) OF THIS 1,084
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 1,086
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 1,088
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 1,089
FOLLOWING:
(a) THE HEALTH INSURING CORPORATION OR ANY OFFICER, 1,091
DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING 1,092
24
CORPORATION;
(b) THE ENROLLEE, THE ENROLLEE'S PROVIDER, OR THE PRACTICE 1,094
GROUP OF THE ENROLLEE'S PROVIDER; 1,095
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 1,097
SERVICE REQUESTED BY THE ENROLLEE WOULD BE PROVIDED; 1,098
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 1,100
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE ENROLLEE. 1,101
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 1,103
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 1,104
CIRCUMSTANCES:
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 1,106
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 1,107
THE HEALTH INSURING CORPORATION. 1,108
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 1,110
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 1,111
THE HEALTH INSURING CORPORATION. 1,112
(c) THE CLINICAL PEER IS A PARTICIPATING PROVIDER BUT WAS 1,114
NOT INVOLVED WITH THE HEALTH INSURING CORPORATION'S ADVERSE 1,115
DETERMINATION.
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 1,117
HEALTH INSURING CORPORATION FROM PAYING THE INDEPENDENT REVIEW 1,118
ORGANIZATION FOR THE CONDUCT OF THE REVIEW. 1,119
(5) AN ENROLLEE SHALL NOT BE REQUIRED TO PAY FOR ANY PART 1,121
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 1,122
BY THE HEALTH INSURING CORPORATION. 1,123
(6)(a) THE HEALTH INSURING CORPORATION SHALL PROVIDE TO 1,126
THE INDEPENDENT REVIEW ORGANIZATION CONDUCTING THE REVIEW A COPY 1,127
OF THOSE RECORDS IN ITS POSSESSION THAT ARE RELEVANT TO THE 1,128
ENROLLEE'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL 1,129
BE USED SOLELY FOR THE PURPOSE OF THIS DIVISION. 1,130
AT THE REQUEST OF THE INDEPENDENT REVIEW ORGANIZATION, THE 1,133
HEALTH INSURING CORPORATION, ENROLLEE, OR THE PROVIDER OR HEALTH 1,134
CARE FACILITY RENDERING HEALTH CARE SERVICES TO THE ENROLLEE 1,135
SHALL PROVIDE ANY ADDITIONAL INFORMATION THE INDEPENDENT REVIEW 1,136
25
ORGANIZATION REQUESTS TO COMPLETE THE REVIEW. A REQUEST FOR 1,138
ADDITIONAL INFORMATION MAY BE MADE IN WRITING, ORALLY, OR BY
ELECTRONIC MEANS. THE INDEPENDENT REVIEW ORGANIZATION SHALL 1,140
SUBMIT THE REQUEST TO THE ENROLLEE AND HEALTH INSURING 1,141
CORPORATION. IF A REQUEST IS SUBMITTED ORALLY OR BY ELECTRONIC 1,142
MEANS TO AN ENROLLEE OR HEALTH INSURING CORPORATION, NOT LATER 1,143
THAN FIVE DAYS AFTER THE REQUEST IS SUBMITTED, THE INDEPENDENT 1,144
REVIEW ORGANIZATION SHALL PROVIDE WRITTEN CONFIRMATION OF THE 1,145
REQUEST. IF THE REVIEW WAS INITIATED BY A PROVIDER OR HEALTH 1,146
CARE FACILITY, A COPY OF THE REQUEST SHALL BE SUBMITTED TO THE 1,147
PROVIDER OR HEALTH CARE FACILITY.
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 1,149
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 1,150
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. AN INDEPENDENT 1,152
REVIEW ORGANIZATION THAT DOES NOT MAKE A DECISION FOR THIS REASON 1,153
SHALL NOTIFY THE ENROLLEE AND THE HEALTH INSURING CORPORATION 1,154
THAT A DECISION IS NOT BEING MADE. THE NOTICE MAY BE MADE IN 1,155
WRITING, ORALLY, OR BY ELECTRONIC MEANS. AN ORAL OR ELECTRONIC 1,156
NOTICE SHALL BE CONFIRMED IN WRITING NOT LATER THAN FIVE DAYS 1,157
AFTER THE ORAL OR ELECTRONIC NOTICE IS MADE. IF THE REVIEW WAS 1,158
INITIATED BY A PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE 1,159
NOTICE SHALL BE SUBMITTED TO THE PROVIDER OR HEALTH CARE 1,160
FACILITY.
(7) THE HEALTH INSURING CORPORATION MAY ELECT TO COVER THE 1,163
SERVICE REQUESTED AND TERMINATE THE REVIEW. THE HEALTH INSURING 1,164
CORPORATION SHALL NOTIFY THE ENROLLEE AND ALL OTHER PARTIES 1,165
INVOLVED WITH THE DECISION BY MAIL OR, WITH THE CONSENT OR 1,166
APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS.
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 1,168
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 1,169
THE FOLLOWING:
(a) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,171
CORPORATION, THE ENROLLEE, THE ENROLLEE'S PROVIDER, AND THE 1,172
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE, INCLUDING 1,174
26
THE FOLLOWING:
(i) THE ENROLLEE'S MEDICAL RECORDS; 1,176
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 1,178
BY THE HEALTH INSURING CORPORATION TO MAKE ITS DECISION. 1,179
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,180
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,181
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY 1,183
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 1,186
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 1,187
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 1,188
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 1,189
AND RESEARCH; 1,190
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,192
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 1,193
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY 1,194
RELEVANT NATIONAL MEDICAL SOCIETIES. 1,195
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 1,197
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 1,198
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 1,202
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 1,205
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 1,206
COPY OF ITS DECISION TO THE HEALTH INSURING CORPORATION AND THE 1,207
ENROLLEE. IF THE ENROLLEE'S PROVIDER OR THE HEALTH CARE FACILITY 1,208
RENDERING HEALTH CARE SERVICES TO THE ENROLLEE REQUESTED THE 1,209
REVIEW, THE INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A 1,210
COPY OF ITS DECISION TO THE ENROLLEE'S PROVIDER OR THE HEALTH 1,211
CARE FACILITY. 1,212
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 1,214
INCLUDE A DESCRIPTION OF THE ENROLLEE'S CONDITION AND THE 1,216
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 1,217
CLINICAL RATIONALE FOR THE DECISION. 1,218
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 1,220
27
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 1,221
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 1,222
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 1,223
AND COST EFFECTIVENESS.
(F) THE HEALTH INSURING CORPORATION SHALL PROVIDE ANY 1,225
COVERAGE DETERMINED BY THE INDEPENDENT REVIEW ORGANIZATION'S 1,226
DECISION TO BE MEDICALLY NECESSARY, SUBJECT TO THE OTHER TERMS, 1,227
LIMITATIONS, AND CONDITIONS OF THE ENROLLEE'S CONTRACT. THE 1,228
DECISION SHALL APPLY ONLY TO THE INDIVIDUAL ENROLLEE'S EXTERNAL 1,229
REVIEW.
Sec. 1753.24 1751.85. (A) Each health insuring 1,238
corporation shall establish a reasonable external, independent 1,241
review process to examine the health insuring corporation's 1,242
coverage decisions for enrollees who meet all of the following 1,243
criteria:
(1) The enrollee has a terminal condition that, according 1,245
to the current diagnosis of the enrollee's physician, has a high 1,246
probability of causing death within two years. 1,247
(2) THE ENROLLEE REQUESTS A REVIEW NOT LATER THAN SIXTY 1,250
DAYS AFTER RECEIPT BY THE ENROLLEE OF NOTICE OF THE RESULT OF AN 1,251
INTERNAL REVIEW UNDER SECTION 1751.83 OF THE REVISED CODE. 1,252
(3) The enrollee's physician certifies that the enrollee 1,254
has the condition described in division (A)(1) of this section 1,256
and any of the following situations are applicable: 1,257
(a) Standard therapies have not been effective in 1,259
improving the condition of the enrollee; 1,261
(b) Standard therapies are not medically appropriate for 1,264
the enrollee;
(c) There is no standard therapy covered by the health 1,267
insuring corporation that is more beneficial than therapy 1,268
described in division (A)(3)(4) of this section. 1,269
(3)(4) The enrollee's physician has recommended a drug, 1,271
device, procedure, or other therapy that the physician certifies, 1,273
in writing, is likely to be more beneficial to the enrollee, in 1,274
28
the physician's opinion, than standard therapies, or, the 1,276
enrollee has requested a therapy that has been found in a
preponderance of peer-reviewed published studies to be associated 1,277
with effective clinical outcomes for the same condition. 1,278
(4)(5) The enrollee has been denied coverage by the health 1,280
insuring corporation for a drug, device, procedure, or other 1,284
therapy recommended or requested pursuant to division (A)(3)(4) 1,285
of this section, and has exhausted all THE HEALTH INSURING 1,286
CORPORATION'S internal appeals REVIEW PROCESS ESTABLISHED 1,287
PURSUANT TO SECTION 1751.83 OF THE REVISED CODE. 1,289
(5)(6) The drug, device, procedure, or other therapy, 1,291
recommended or requested pursuant to division (A)(3) of this 1,294
section, FOR WHICH COVERAGE HAS BEEN DENIED would be a covered 1,295
health care service except for the health insuring corporation's 1,297
determination that the drug, device, procedure, or other therapy 1,299
is experimental or investigational.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 1,301
THE ENROLLEE'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 1,302
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 1,303
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. WHEN AN 1,304
ORAL OR ELECTRONIC REQUEST FOR REVIEW IS MADE, WRITTEN 1,305
CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED TO THE HEALTH
INSURING CORPORATION NOT LATER THAN FIVE DAYS AFTER THE ORAL OR 1,306
WRITTEN REQUEST IS SUBMITTED. 1,307
(C) The external, independent review process established 1,310
by a health insuring corporation shall meet all of the following 1,311
criteria:
(1) Except as provided in division (C)(E) of this section, 1,313
the process shall offer AFFORD all enrollees who meet the 1,315
criteria set forth in division (A) of this section the 1,317
opportunity to have the health insuring corporation's decision to 1,318
deny coverage of the recommended or requested therapy reviewed 1,320
under the process. Each eligible enrollee shall be notified of 1,322
that opportunity within five business days after the health 1,323
29
insuring corporation denies coverage.
(2) The review of the health insuring corporation's 1,325
decision shall be conducted by experts selected by an independent 1,326
entity that has been retained by the health insuring corporation 1,328
for this purpose. The independent entity shall be either an 1,331
academic medical center or an entity that has as its primary 1,333
function, and that receives a majority of its revenue from, the 1,334
provision of expert reviews and related services REVIEW 1,335
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 1,336
SECTION 3901.80 OF THE REVISED CODE. 1,337
The independent entity REVIEW ORGANIZATION shall select a 1,339
panel to conduct the review, which panel shall be composed of at 1,342
least three physicians or other providers who, THROUGH CLINICAL 1,343
EXPERIENCE IN THE PAST THREE YEARS, are experts in the treatment 1,344
of the enrollee's medical condition and knowledgeable about the 1,346
recommended or requested therapy. If the independent entity 1,347
retained by the health insuring corporation is an academic 1,349
medical center, the panel may include experts affiliated with or 1,350
employed by the academic medical center. 1,351
In either of the following circumstances, an exception may 1,354
be made to the requirement that the review be conducted by an 1,355
expert panel composed of a minimum of three physicians or other 1,356
providers:
(a) A review may be conducted by an expert panel composed 1,359
of only two physicians or other providers if an enrollee has 1,360
consented in writing to a review by the smaller panel; 1,361
(b) A review may be conducted by a single expert physician 1,364
or other provider if only one expert physician or other provider 1,365
is available for the review.
(3) Neither the health insuring corporation nor the 1,367
enrollee shall choose, or control the choice of, the physician or 1,369
other provider experts.
(4) Neither the THE SELECTED experts nor, ANY HEALTH CARE 1,372
FACILITY WITH WHICH AN EXPERT IS AFFILIATED, AND the independent 1,373
30
entity REVIEW ORGANIZATION arranging for the experts' review, 1,374
shall NOT have any professional, familial, or financial 1,375
affiliation with the ANY OF THE FOLLOWING:
(a) THE health insuring corporation, except that OR ANY 1,378
OFFICER, DIRECTOR, OR MANAGERIAL EMPLOYEE OF THE HEALTH INSURING
CORPORATION; 1,379
(b) THE ENROLLEE, THE ENROLLEE'S PHYSICIAN, OR THE 1,381
PRACTICE GROUP OF THE ENROLLEE'S PHYSICIAN; 1,382
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 1,384
REQUESTED THERAPY WOULD BE PROVIDED; 1,385
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 1,387
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 1,388
REQUESTED THERAPY. 1,389
HOWEVER, experts affiliated with academic medical centers 1,392
who provide healthcare HEALTH CARE services to enrollees of the 1,393
health insuring corporation may serve as experts on the review 1,395
panel. This FURTHER, EXPERTS WITH STAFF PRIVILEGES AT A HEALTH 1,397
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO ENROLLEES OF 1,398
THE HEALTH INSURING CORPORATION, AS WELL AS EXPERTS WHO ARE 1,399
PARTICIPATING PROVIDERS, BUT WHO WERE NOT INVOLVED WITH THE 1,400
HEALTH INSURING CORPORATION'S DENIAL OF COVERAGE FOR THE THERAPY 1,401
UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THESE 1,402
nonaffiliation provision does PROVISIONS DO not preclude a health 1,404
insuring corporation from paying for the experts' review, as
specified in division (B)(C)(5) of this section. The experts 1,406
shall have no patient-physician relationship or other affiliation 1,408
with an enrollee whose request for therapy is under review or 1,409
with a provider whose recommendation for therapy is under review. 1,410
(5) Enrollees shall not be required to pay for ANY PART OF 1,412
the external, independent COST OF THE review. The costs COST of 1,414
the review shall be borne by the health insuring corporation. 1,416
(6) The health insuring corporation shall provide to the 1,418
independent entity REVIEW ORGANIZATION arranging for the experts' 1,419
review and to the enrollee and the enrollee's physician a copy of 1,420
31
those medical records in the health insuring corporation's 1,421
possession that are relevant to the enrollee's MEDICAL condition 1,424
for which therapy has been recommended or requested AND THE 1,425
REVIEW. The medical records shall be disclosed solely to the 1,428
expert reviewers and shall be used solely for the purpose of this
section. AT THE REQUEST OF THE EXPERT REVIEWERS, THE HEALTH 1,430
INSURING CORPORATION OR THE PHYSICIAN RECOMMENDING THE THERAPY 1,431
SHALL PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT 1,432
REVIEWERS REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS 1,433
NOT REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT 1,434
RECEIVED ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS 1,435
NECESSARY TO COMPLETE THE REVIEW. 1,436
(7)(a) The opinions of the experts on the panel shall be 1,438
rendered within thirty days after the enrollee's request for 1,441
review. If the enrollee's physician determines that a therapy 1,443
would be significantly less effective if not promptly initiated, 1,444
the opinions shall be rendered within seven days after the
enrollee's request for review. 1,445
(b) IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 1,447
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 1,449
(i) INFORMATION SUBMITTED BY THE HEALTH INSURING 1,451
CORPORATION, THE ENROLLEE, AND THE ENROLLEE'S PHYSICIAN, 1,452
INCLUDING THE ENROLLEE'S MEDICAL RECORDS AND THE STANDARDS, 1,453
CRITERIA, AND CLINICAL RATIONALE USED BY THE HEALTH INSURING 1,454
CORPORATION TO REACH ITS COVERAGE DECISION; 1,455
(ii) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 1,457
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 1,458
ORGANIZATIONS;
(iii) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 1,460
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 1,461
RECOGNIZED MEDICAL EXPERTS; 1,462
(iv) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 1,464
MEDICAL SOCIETIES; 1,465
(v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 1,467
32
EFFECTIVENESS.
(8) Each expert on the panel shall provide the independent 1,469
entity REVIEW ORGANIZATION with a professional opinion as to 1,471
whether there is sufficient evidence to demonstrate that the 1,472
recommended or requested therapy is likely to be more beneficial
to the enrollee than standard therapies. 1,474
(9) Each expert's opinion shall be presented in written 1,476
form and shall include the following information: 1,478
(a) A description of the enrollee's condition; 1,480
(b) A description of the indicators relevant to 1,482
determining whether there is sufficient evidence to demonstrate 1,483
that the recommended or requested therapy is more likely than not 1,485
to be more beneficial to the enrollee than standard therapies; 1,486
(c) A description and analysis of any relevant findings 1,488
published in peer-reviewed medical or scientific literature or 1,489
the published opinions of medical experts or specialty societies; 1,490
(d) A description of the enrollee's suitability to receive 1,492
the recommended or requested therapy according to a treatment 1,493
protocol in a clinical trial, if applicable. 1,495
(10) The independent entity REVIEW ORGANIZATION shall 1,497
provide the health insuring corporation with the opinions of the 1,499
experts. The health insuring corporation shall make the experts' 1,500
opinions available to the enrollee and the enrollee's physician, 1,502
upon request.
(11) The decision OPINION of the majority of the experts 1,504
on the panel, rendered pursuant to division (B)(C)(8) of this 1,506
section, is binding on the health insuring corporation with 1,508
respect to that enrollee. If the opinions of the experts on the 1,509
panel are evenly divided as to whether the therapy should be 1,510
covered, then the health insuring corporation's final decision 1,511
shall be in favor of coverage. If less than a majority of the 1,513
experts on the panel recommend coverage of the therapy, the 1,514
health insuring corporation may, in its discretion, cover the 1,515
therapy. However, any coverage provided pursuant to division 1,516
33
(B)(C)(11) of this section is subject to the terms, LIMITATIONS, 1,518
and conditions of the enrollee's contract with the health 1,520
insuring corporation.
(12) The health insuring corporation shall have written 1,522
policies describing the external, independent review process. 1,524
The health insuring corporation shall disclose the availability 1,525
of the external, independent review process in the health 1,526
insuring corporation's evidence of coverage and disclosure forms. 1,528
(C)(D) AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW 1,531
PROCESS, THE HEALTH INSURING CORPORATION MAY ELECT TO COVER THE 1,532
RECOMMENDED OR REQUESTED HEALTH CARE SERVICE AND TERMINATE THE 1,533
REVIEW. THE HEALTH INSURING CORPORATION SHALL NOTIFY THE 1,534
ENROLLEE AND ALL OTHER PARTIES INVOLVED BY MAIL OR, WITH THE 1,535
CONSENT OR APPROVAL OF THE ENROLLEE, BY ELECTRONIC MEANS. 1,536
(E) If a health insuring corporation's initial denial of 1,538
coverage for a therapy recommended or requested pursuant to 1,539
division (A)(3)(4) of this section is based upon an external, 1,540
independent review of that therapy meeting the requirements of 1,541
division (B)(C) of this section, this section shall not be a 1,542
basis for requiring a second external, independent review of the 1,543
recommended or requested therapy. 1,544
(D)(F) The health insuring corporation shall annually file 1,546
a certificate with the superintendent of insurance certifying its 1,547
compliance with the requirements of this section. 1,548
Sec. 1751.87. NOTHING IN SECTIONS 1751.77 TO 1751.85 OF 1,550
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 1,551
AGAINST ANY OF THE FOLLOWING:
(A) AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO 1,554
EMPLOYEES THROUGH A HEALTH INSURING CORPORATION;
(B) A CLINICAL PEER, MEDICAL EXPERT, OR INDEPENDENT REVIEW 1,556
ORGANIZATION THAT PARTICIPATES IN AN EXTERNAL REVIEW UNDER 1,559
SECTION 1751.84 OR 1751.85 OF THE REVISED CODE;
(C) A HEALTH INSURING CORPORATION THAT PROVIDES COVERAGE 1,562
FOR BENEFITS IN ACCORDANCE WITH DIVISION (F) OF SECTION 1751.84 1,563
34
OR DIVISION (C)(11) OF SECTION 1751.85 OF THE REVISED CODE. 1,565
Sec. 1751.88. CONSISTENT WITH THE RULES OF EVIDENCE, A 1,568
WRITTEN DECISION OR OPINION PREPARED BY OR FOR AN INDEPENDENT 1,569
REVIEW ORGANIZATION UNDER SECTION 1751.84 OR 1751.85 OF THE 1,571
REVISED CODE SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO 1,572
THE COVERAGE DECISION THAT WAS THE SUBJECT OF THE DECISION OR 1,573
OPINION. THE INDEPENDENT REVIEW ORGANIZATION'S DECISION OR 1,574
OPINION SHALL BE PRESUMED TO BE A SCIENTIFICALLY VALID AND 1,577
ACCURATE DESCRIPTION OF THE STATE OF MEDICAL KNOWLEDGE AT THE
TIME IT WAS WRITTEN. 1,578
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 1,580
ACTION RELATED TO A HEALTH INSURING CORPORATION'S COVERAGE 1,581
DECISION INVOLVING AN INVESTIGATIONAL OR EXPERIMENTAL DRUG, 1,583
DEVICE, OR TREATMENT MAY INTRODUCE INTO EVIDENCE ANY APPLICABLE 1,584
MEDICARE REIMBURSEMENT STANDARDS ESTABLISHED UNDER TITLE XVIII OF 1,585
THE "SOCIAL SECURITY ACT," 49 STAT. 620(1935), 42 U.S.C.A. 301, 1,587
AS AMENDED. 1,588
Sec. 1751.89. SECTIONS 1751.77 TO 1751.85 OF THE REVISED 1,591
CODE DO NOT APPLY TO EITHER OF THE FOLLOWING:
(A) COVERAGE PROVIDED TO BENEFICIARIES ENROLLED IN THE 1,593
MEDICARE+CHOICE PROGRAM OPERATED UNDER TITLE XVIII OF THE "SOCIAL 1,595
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED; 1,596
(B) COVERAGE PROVIDED TO RECIPIENTS OF ASSISTANCE UNDER 1,598
THE MEDICAID PROGRAM OPERATED PURSUANT TO CHAPTER 5111. OF THE 1,600
REVISED CODE.
Sec. 1753.13. EVERY INDIVIDUAL OR GROUP HEALTH INSURING 1,602
CORPORATION POLICY, CONTRACT, OR AGREEMENT THAT PROVIDES BASIC 1,603
HEALTH CARE SERVICES BUT DOES NOT ALLOW DIRECT ACCESS TO 1,604
OBSTETRICIANS OR GYNECOLOGISTS SHALL PERMIT A FEMALE ENROLLEE TO 1,605
OBTAIN COVERED OBSTETRIC AND GYNECOLOGICAL SERVICES FROM A 1,606
PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST WITHOUT OBTAINING A 1,608
REFERRAL FROM THE ENROLLEE'S PRIMARY CARE PROVIDER. 1,609
NO INDIVIDUAL OR GROUP HEALTH INSURING CORPORATION POLICY, 1,611
CONTRACT, OR AGREEMENT MAY LIMIT THE NUMBER OF ALLOWABLE VISITS 1,612
35
TO A PARTICIPATING OBSTETRICIAN OR GYNECOLOGIST. A HEALTH 1,613
INSURING CORPORATION MAY REQUIRE A PARTICIPATING OBSTETRICIAN OR 1,614
GYNECOLOGIST TO COMPLY WITH THE HEALTH INSURING CORPORATION'S 1,615
COVERAGE PROTOCOLS AND PROCEDURES, INCLUDING UTILIZATION REVIEW, 1,616
FOR OBSTETRIC AND GYNECOLOGICAL SERVICES. 1,617
A HEALTH INSURING CORPORATION POLICY, CONTRACT, OR 1,619
AGREEMENT MAY NOT IMPOSE ADDITIONAL COPAYMENTS FOR DIRECTLY 1,621
ACCESSED OBSTETRIC AND GYNECOLOGICAL SERVICES, UNLESS THE POLICY, 1,622
CONTRACT, OR AGREEMENT IMPOSES ADDITIONAL COPAYMENTS FOR DIRECT
ACCESS TO ANY PARTICIPATING PROVIDER OTHER THAN A PRIMARY CARE 1,623
PROVIDER.
Sec. 3901.80. AS USED IN SECTIONS 3901.80 TO 3901.83 OF 1,625
THE REVISED CODE, "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME 1,626
MEANINGS AS IN SECTION 1751.77 OF THE REVISED CODE.
(A) THE SUPERINTENDENT OF INSURANCE SHALL ACCREDIT 1,629
INDEPENDENT REVIEW ORGANIZATIONS FOR THE PURPOSES OF EXTERNAL
REVIEWS CONDUCTED UNDER SECTIONS 1751.84, 1751.85, 3923.67, 1,631
3923.68, 3923.76, AND 3923.77 OF THE REVISED CODE. THE
SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER 119. OF THE 1,632
REVISED CODE AND IN CONSULTATION WITH THE DIRECTOR OF HEALTH, 1,633
ADOPT RULES GOVERNING THE ACCREDITATION OF INDEPENDENT REVIEW 1,634
ORGANIZATIONS. IN DEVELOPING THE RULES, THE SUPERINTENDENT MAY 1,635
TAKE INTO CONSIDERATION THE STANDARDS ESTABLISHED BY NATIONAL 1,636
ORGANIZATIONS THAT ACCREDIT ORGANIZATIONS PROVIDING EXPERT 1,637
REVIEWS AND RELATED SERVICES. THE SUPERINTENDENT, AFTER 1,638
REVIEWING THE ACCREDITATION PROCESS USED BY A NATIONAL 1,639
ORGANIZATION TO ACCREDIT AN INDEPENDENT REVIEW ORGANIZATION, MAY 1,640
DETERMINE THAT ACCREDITATION BY THE NATIONAL ORGANIZATION 1,641
CONSTITUTES ACCREDITATION BY THE SUPERINTENDENT. THE 1,642
SUPERINTENDENT SHALL NOT ACCREDIT ANY INDEPENDENT REVIEW 1,643
ORGANIZATION THAT IS OPERATED BY A NATIONAL, STATE, OR LOCAL
TRADE ASSOCIATION OF HEALTH BENEFIT PLANS OR HEALTH CARE 1,644
PROVIDERS.
(B) EACH INDEPENDENT REVIEW ORGANIZATION SHALL USE THE 1,646
36
SERVICES OF CLINICAL PEERS OUTSIDE THE STAFF OF THE INDEPENDENT 1,647
REVIEW ORGANIZATION TO CONDUCT EXTERNAL REVIEWS. NONE OF THE 1,648
FOLLOWING SHALL CHOOSE, OR CONTROL THE CHOICE OF, THE CLINICAL 1,649
PEERS:
(1) A HEALTH INSURING CORPORATION; 1,651
(2) AN ENROLLEE; 1,653
(3) AN INSURER; 1,655
(4) AN INSURED; 1,657
(5) A PUBLIC EMPLOYEE BENEFIT PLAN; 1,659
(6) A PLAN MEMBER. 1,661
(C) THE SUPERINTENDENT SHALL MAINTAIN A RANDOMLY ORGANIZED 1,663
ROSTER OF INDEPENDENT REVIEW ORGANIZATIONS ACCREDITED UNDER THIS 1,664
SECTION FOR PURPOSES OF ASSIGNING INDEPENDENT REVIEW 1,665
ORGANIZATIONS TO CONDUCT EXTERNAL REVIEWS. THE SUPERINTENDENT 1,666
MAY, IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, ADOPT 1,667
RULES GOVERNING THE ASSIGNMENT OF INDEPENDENT REVIEW 1,668
ORGANIZATIONS.
ON RECEIPT OF A REQUEST BY A HEALTH INSURING CORPORATION, 1,670
INSURER, OR PUBLIC EMPLOYEE BENEFIT PLAN, THE SUPERINTENDENT 1,671
SHALL RANDOMLY ASSIGN TWO INDEPENDENT REVIEW ORGANIZATIONS THAT 1,672
ARE ACCREDITED UNDER DIVISION (A) OF THIS SECTION. AFTER RECEIPT 1,673
OF THE NAMES OF THE TWO INDEPENDENT REVIEW ORGANIZATIONS, THE 1,675
HEALTH INSURING CORPORATION, INSURER, OR PUBLIC EMPLOYEE BENEFIT 1,676
PLAN SHALL SELECT ONE OF THE ASSIGNED INDEPENDENT REVIEW
ORGANIZATIONS TO CONDUCT THE EXTERNAL REVIEW. 1,677
NO HEALTH INSURING CORPORATION, INSURER, OR PUBLIC EMPLOYEE 1,679
BENEFIT PLAN SHALL ENGAGE IN A PATTERN OF EXCLUDING A PARTICULAR 1,680
INDEPENDENT REVIEW ORGANIZATION BASED ON PREVIOUS FINDINGS ON 1,681
BEHALF OF ENROLLEES, INSUREDS, OR PLAN MEMBERS. IF THE 1,682
SUPERINTENDENT MAKES SUCH A FINDING, IT IS AN UNFAIR TRADE 1,683
PRACTICE.
Sec. 3901.81. AN INDEPENDENT REVIEW ORGANIZATION SELECTED 1,685
UNDER SECTION 3901.80 OF THE REVISED CODE TO CONDUCT AN EXTERNAL 1,686
REVIEW UNDER SECTION 1751.84, 3923.67, OR 3923.76 OF THE REVISED 1,687
37
CODE SHALL UTILIZE THE SERVICES OF CLINICAL PEERS WHO HAVE 1,688
EXPERTISE IN THE TREATMENT OF THE MEDICAL CONDITION OF THE 1,690
ENROLLEE, INSURED, OR PLAN MEMBER AND CLINICAL EXPERIENCE IN THE 1,691
PAST THREE YEARS WITH THE SERVICE REQUESTED OR RECOMMENDED BY THE 1,692
ENROLLEE, INSURED, OR PLAN MEMBER OR THE PROVIDER OF THE 1,693
ENROLLEE, INSURED, OR PLAN MEMBER. THE REVIEW SHALL BE CONDUCTED 1,694
BY A SINGLE CLINICAL PEER, UNLESS THE HEALTH INSURING 1,695
CORPORATION, INSURER, OR PUBLIC EMPLOYEE BENEFIT PLAN DETERMINES 1,697
THAT MORE THAN ONE CLINICAL PEER IS NEEDED. THE CLINICAL PEER 1,698
MUST HOLD A LICENSE THAT IS NOT RESTRICTED IN ANY MANNER BY THE 1,699
STATE IN WHICH THE CLINICAL PEER IS LICENSED. THE CLINICAL PEER 1,700
SHALL NOT HAVE BEEN DISCIPLINED OR SANCTIONED BY A HOSPITAL OR 1,702
GOVERNMENT ENTITY BASED ON THE QUALITY OF CARE PROVIDED BY THE 1,703
CLINICAL PEER. IN THE CASE OF A PHYSICIAN, THE CLINICAL PEER 1,704
MUST BE CERTIFIED BY A NATIONALLY RECOGNIZED MEDICAL SPECIALTY 1,705
BOARD IN THE AREA THAT IS THE SUBJECT OF THE REVIEW.
Sec. 3901.82. (A) EACH INDEPENDENT REVIEW ORGANIZATION 1,708
THAT CONDUCTS EXTERNAL REVIEWS UNDER SECTION 1751.84, 1751.85, 1,712
3923.67, 3923.68, 3923.76, OR 3923.77 OF THE REVISED CODE SHALL 1,713
ANNUALLY REPORT THE FOLLOWING INFORMATION TO THE SUPERINTENDENT 1,715
OF INSURANCE IN A FORMAT PRESCRIBED BY THE SUPERINTENDENT: 1,716
(1) THE NUMBER OF REVIEWS CONDUCTED; 1,718
(2) THE NUMBER OF REVIEWS DECIDED IN FAVOR OF ENROLLEES, 1,720
INSUREDS, AND PLAN MEMBERS AND THE NUMBER DECIDED IN FAVOR OF 1,722
HEALTH INSURING CORPORATIONS, INSURERS, AND PUBLIC EMPLOYEE 1,723
BENEFIT PLANS;
(3) THE AVERAGE TIME REQUIRED TO CONDUCT A REVIEW; 1,725
(4) THE NUMBER AND PERCENTAGE OF REVIEWS IN WHICH A 1,727
DECISION WAS NOT REACHED IN THE TIME REQUIRED UNDER DIVISION (D) 1,728
OF SECTION 1751.84, DIVISION (C) OF SECTION 1751.85, DIVISION (D) 1,729
OF SECTION 3923.67, DIVISION (C) OF SECTION 3923.68, DIVISION (D) 1,731
OF SECTION 3923.76, OR DIVISION (C) OF SECTION 3923.77 OF THE 1,732
REVISED CODE; 1,733
(5) A SUMMARY OF THE DIAGNOSES, DRUGS, DEVICES, SERVICES, 1,735
38
PROCEDURES, AND THERAPIES THAT HAVE BEEN THE SUBJECT OF EXTERNAL 1,736
REVIEW;
(6) THE COSTS ASSOCIATED WITH EXTERNAL REVIEWS, INCLUDING 1,738
THE RATES CHARGED BY THE INDEPENDENT REVIEW ORGANIZATION TO 1,740
CONDUCT THE REVIEWS;
(7) THE MEDICAL SPECIALTY OR TYPE OF PROVIDER USED TO 1,742
CONDUCT EACH EXTERNAL REVIEW, AS RELATED TO THE SPECIFIC MEDICAL 1,743
CONDITION OF THE ENROLLEE, INSURED, OR PLAN MEMBER; 1,744
(8) ANY ADDITIONAL INFORMATION REQUIRED BY THE 1,746
SUPERINTENDENT BY RULE ADOPTED PURSUANT TO DIVISION (C) OF THIS 1,747
SECTION.
(B) THE SUPERINTENDENT OF INSURANCE SHALL COMPLY WITH 1,749
APPLICABLE STATE AND FEDERAL LAWS RELATED TO THE CONFIDENTIALITY 1,750
OF MEDICAL RECORDS.
(C) THE SUPERINTENDENT MAY, IN ACCORDANCE WITH CHAPTER 1,752
119. OF THE REVISED CODE, ADOPT RULES REQUIRING INDEPENDENT 1,755
REVIEW ORGANIZATIONS TO PROVIDE ADDITIONAL INFORMATION ON THE 1,757
CONSIDERATION AND DISPOSITION OF EXTERNAL REVIEWS BROUGHT UNDER 1,760
SECTION 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, OR 3923.77
OF THE REVISED CODE. 1,761
(D) THE SUPERINTENDENT SHALL COMPILE AND ANNUALLY PUBLISH 1,763
THE INFORMATION COLLECTED UNDER THIS SECTION AND REPORT THE 1,766
INFORMATION TO THE GOVERNOR, THE SPEAKER AND MINORITY LEADER OF 1,767
THE HOUSE OF REPRESENTATIVES, THE PRESIDENT AND MINORITY LEADER 1,769
OF THE SENATE, AND THE CHAIRS AND RANKING MINORITY MEMBERS OF THE 1,770
HOUSE AND SENATE COMMITTEES WITH JURISDICTION OVER HEALTH AND 1,772
INSURANCE ISSUES.
Sec. 3901.83. WHEN A RECORD CONTAINING INFORMATION 1,774
PERTAINING TO THE MEDICAL HISTORY, DIAGNOSIS, PROGNOSIS, OR 1,775
MEDICAL CONDITION OF AN ENROLLEE OF A HEALTH INSURING 1,776
CORPORATION, INSURED OF AN INSURER, OR PLAN MEMBER OF A PUBLIC 1,777
EMPLOYEE BENEFIT PLAN IS PROVIDED TO THE SUPERINTENDENT OF 1,778
INSURANCE FOR ANY REASON UNDER SECTIONS 1751.77 TO 1751.88, 1,779
3923.66 TO 3923.70, OR 3923.75 TO 3923.79 OF THE REVISED CODE, 1,782
39
REGARDLESS OF THE SOURCE, THE SUPERINTENDENT SHALL MAINTAIN THE 1,783
CONFIDENTIALITY OF THE RECORD. THE RECORD IN THE 1,784
SUPERINTENDENT'S POSSESSION IS NOT A PUBLIC RECORD UNDER SECTION 1,785
149.43 OF THE REVISED CODE, EXCEPT TO THE EXTENT THAT INFORMATION 1,787
FROM THE RECORD IS USED IN PREPARING REPORTS UNDER SECTION 1,788
3901.82 OF THE REVISED CODE.
Sec. 3901.84. AN INDEPENDENT REVIEW ORGANIZATION AND ANY 1,790
MEDICAL EXPERT OR CLINICAL PEER THE ORGANIZATION USES IN 1,792
CONDUCTING AN EXTERNAL REVIEW UNDER SECTION 1751.84, 1751.85, 1,793
3923.67, 3923.68, 3923.76, OR 3923.77 OF THE REVISED CODE IS NOT 1,794
LIABLE IN DAMAGES IN A CIVIL ACTION FOR INJURY, DEATH, OR LOSS TO 1,796
PERSON OR PROPERTY AND IS NOT SUBJECT TO PROFESSIONAL 1,797
DISCIPLINARY ACTION FOR MAKING, IN GOOD FAITH, ANY FINDING,
CONCLUSION, OR DETERMINATION REQUIRED TO COMPLETE THE EXTERNAL 1,799
REVIEW.
THIS SECTION DOES NOT GRANT IMMUNITY FROM CIVIL LIABILITY 1,803
OR PROFESSIONAL DISCIPLINARY ACTION TO AN INDEPENDENT REVIEW
ORGANIZATION, MEDICAL EXPERT, OR CLINICAL PEER FOR AN ACTION THAT 1,804
IS OUTSIDE THE SCOPE OF AUTHORITY GRANTED UNDER SECTION 1751.84, 1,806
1751.85, 3923.67, 3923.68, 3923.76, OR 3923.77 OF THE REVISED 1,808
CODE.
Sec. 3923.65. (A) AS USED IN THIS SECTION: 1,810
(1) "EMERGENCY MEDICAL CONDITION" MEANS A MEDICAL 1,812
CONDITION THAT MANIFESTS ITSELF BY SUCH ACUTE SYMPTOMS OF 1,813
SUFFICIENT SEVERITY, INCLUDING SEVERE PAIN, THAT A PRUDENT 1,814
LAYPERSON WITH AVERAGE KNOWLEDGE OF HEALTH AND MEDICINE COULD 1,815
REASONABLY EXPECT THE ABSENCE OF IMMEDIATE MEDICAL ATTENTION TO 1,816
RESULT IN ANY OF THE FOLLOWING: 1,817
(a) PLACING THE HEALTH OF THE INDIVIDUAL OR, WITH RESPECT 1,819
TO A PREGNANT WOMAN, THE HEALTH OF THE WOMAN OR HER UNBORN CHILD, 1,820
IN SERIOUS JEOPARDY; 1,821
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 1,823
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 1,825
(2) "EMERGENCY SERVICES" MEANS THE FOLLOWING: 1,827
40
(a) A MEDICAL SCREENING EXAMINATION, AS REQUIRED BY 1,829
FEDERAL LAW, THAT IS WITHIN THE CAPABILITY OF THE EMERGENCY 1,830
DEPARTMENT OF A HOSPITAL, INCLUDING ANCILLARY SERVICES ROUTINELY 1,832
AVAILABLE TO THE EMERGENCY DEPARTMENT, TO EVALUATE AN EMERGENCY 1,833
MEDICAL CONDITION; 1,834
(b) SUCH FURTHER MEDICAL EXAMINATION AND TREATMENT THAT 1,836
ARE REQUIRED BY FEDERAL LAW TO STABILIZE AN EMERGENCY MEDICAL 1,837
CONDITION AND ARE WITHIN THE CAPABILITIES OF THE STAFF AND 1,839
FACILITIES AVAILABLE AT THE HOSPITAL, INCLUDING ANY TRAUMA AND 1,840
BURN CENTER OF THE HOSPITAL.
(B) EVERY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND 1,842
ACCIDENT INSURANCE THAT PROVIDES HOSPITAL, SURGICAL, OR MEDICAL 1,843
EXPENSE COVERAGE SHALL COVER EMERGENCY SERVICES WITHOUT REGARD TO 1,844
THE DAY OR TIME THE EMERGENCY SERVICES ARE RENDERED OR TO WHETHER 1,845
THE POLICYHOLDER, THE HOSPITAL'S EMERGENCY DEPARTMENT WHERE THE 1,846
SERVICES ARE RENDERED, OR AN EMERGENCY PHYSICIAN TREATING THE 1,847
POLICYHOLDER, OBTAINED PRIOR AUTHORIZATION FOR THE EMERGENCY 1,848
SERVICES.
(C) EVERY INDIVIDUAL POLICY OR CERTIFICATE FURNISHED BY AN 1,850
INSURER IN CONNECTION WITH ANY SICKNESS AND ACCIDENT INSURANCE 1,852
POLICY SHALL PROVIDE INFORMATION REGARDING THE FOLLOWING: 1,853
(1) THE SCOPE OF COVERAGE FOR EMERGENCY SERVICES; 1,855
(2) THE APPROPRIATE USE OF EMERGENCY SERVICES, INCLUDING 1,857
THE USE OF THE 9-1-1 SYSTEM AND ANY OTHER TELEPHONE ACCESS 1,858
SYSTEMS UTILIZED TO ACCESS PREHOSPITAL EMERGENCY SERVICES; 1,859
(3) ANY COPAYMENTS FOR EMERGENCY SERVICES. 1,861
(D) THIS SECTION DOES NOT APPLY TO ANY INDIVIDUAL OR GROUP 1,863
POLICY OF SICKNESS AND ACCIDENT INSURANCE COVERING ONLY ACCIDENT, 1,864
CREDIT, DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL 1,865
INDEMNITY, MEDICARE SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED 1,866
DISEASE, OR VISION CARE; COVERAGE UNDER A ONE-TIME LIMITED 1,867
DURATION POLICY OF NO LONGER THAN SIX MONTHS; COVERAGE ISSUED AS 1,868
A SUPPLEMENT TO LIABILITY INSURANCE; INSURANCE ARISING OUT OF 1,869
WORKERS' COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL PAYMENT 1,870
41
INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE WITH OR 1,871
WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED TO BE 1,872
CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 1,873
SELF-INSURANCE.
Sec. 3923.66. (A) AS USED IN SECTIONS 3923.66 TO 3923.70 1,875
OF THE REVISED CODE: 1,876
(1) "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME MEANINGS 1,878
AS IN SECTION 1751.77 OF THE REVISED CODE. 1,879
(2) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 1,881
PERSON AUTHORIZED TO ACT ON BEHALF OF AN INSURED WITH RESPECT TO 1,882
HEALTH CARE DECISIONS. 1,883
(B) SECTIONS 3923.66 TO 3923.70 OF THE REVISED CODE DO NOT 1,886
APPLY TO ANY INDIVIDUAL OR GROUP POLICY OF SICKNESS AND ACCIDENT 1,888
INSURANCE COVERING ONLY ACCIDENT, CREDIT, DENTAL, DISABILITY 1,889
INCOME, LONG-TERM CARE, HOSPITAL INDEMNITY, MEDICARE SUPPLEMENT, 1,891
MEDICARE, TRICARE, SPECIFIED DISEASE, OR VISION CARE; COVERAGE 1,892
ISSUED AS A SUPPLEMENT TO LIABILITY INSURANCE; INSURANCE ARISING 1,893
OUT OF WORKERS' COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL 1,894
PAYMENT INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE 1,895
WITH OR WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED 1,896
TO BE CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 1,897
SELF-INSURANCE.
(C) THE SUPERINTENDENT OF INSURANCE SHALL ESTABLISH AND 1,899
MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING REQUESTS FOR REVIEW 1,901
FROM INSUREDS WHO HAVE BEEN DENIED COVERAGE OF A HEALTH CARE 1,902
SERVICE ON THE GROUNDS THAT THE SERVICE IS NOT A SERVICE COVERED 1,903
UNDER THE TERMS OF THE INSURED'S POLICY OR CERTIFICATE. 1,904
ON RECEIPT OF A WRITTEN REQUEST FROM AN INSURED OR 1,906
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 1,907
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 1,908
INSURED'S POLICY OR CERTIFICATE, EXCEPT THAT THE SUPERINTENDENT 1,909
SHALL NOT CONDUCT A REVIEW UNDER THIS SECTION UNLESS THE INSURED 1,910
HAS EXHAUSTED THE INSURER'S INTERNAL REVIEW PROCESS. THE INSURER 1,911
AND THE INSURED OR AUTHORIZED PERSON SHALL PROVIDE THE 1,912
42
SUPERINTENDENT WITH ANY INFORMATION REQUIRED BY THE 1,913
SUPERINTENDENT THAT IS IN THEIR POSSESSION AND IS GERMANE TO THE 1,914
REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 1,916
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 1,917
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 1,918
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 1,919
INSURED'S POLICY OR CERTIFICATE. THE SUPERINTENDENT SHALL NOTIFY 1,920
THE INSURED AND THE INSURER OF ITS DETERMINATION OR THAT IT IS 1,921
NOT ABLE TO MAKE A DETERMINATION BECAUSE THE DETERMINATION 1,922
REQUIRES THE RESOLUTION OF A MEDICAL ISSUE.
IF THE SUPERINTENDENT NOTIFIES THE INSURER THAT MAKING THE 1,924
DETERMINATION REQUIRES THE RESOLUTION OF A MEDICAL ISSUE, THE 1,925
INSURER SHALL AFFORD THE INSURED AN OPPORTUNITY FOR EXTERNAL 1,926
REVIEW UNDER SECTION 3923.67 OR 3923.68 OF THE REVISED CODE. IF 1,927
THE SUPERINTENDENT NOTIFIES THE INSURER THAT THE HEALTH CARE 1,928
SERVICE IS NOT A COVERED SERVICE, THE INSURER IS NOT REQUIRED TO 1,929
COVER THE SERVICE OR AFFORD THE INSURED AN EXTERNAL REVIEW. 1,931
Sec. 3923.67. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 1,934
(C) OF THIS SECTION, AN INSURER SHALL AFFORD AN INSURED AN 1,935
OPPORTUNITY FOR AN EXTERNAL REVIEW OF A COVERAGE DENIAL WHEN 1,936
REQUESTED BY THE INSURED OR AUTHORIZED PERSON, IF BOTH OF THE 1,937
FOLLOWING ARE THE CASE:
(1) THE INSURER HAS DENIED, REDUCED, OR TERMINATED 1,939
COVERAGE FOR WHAT WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT 1,940
THAT THE INSURER HAS DETERMINED THAT THE HEALTH CARE SERVICE IS 1,941
NOT MEDICALLY NECESSARY.
(2) EXCEPT IN THE CASE OF EXPEDITED REVIEW, THE PROPOSED 1,944
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 1,945
COST THE INSURED MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED 1,946
SERVICE IS NOT COVERED BY THE INSURER. 1,947
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 1,949
SECTION, EXCEPT THAT IF AN INSURED WITH A TERMINAL CONDITION 1,950
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 3923.68 OF 1,951
43
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 1,953
THAT SECTION. 1,954
(B) AN INSURED NEED NOT BE AFFORDED A REVIEW UNDER THIS 1,956
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 1,957
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 1,959
SECTION 3923.66 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 1,960
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE INSURED'S POLICY 1,961
OR CERTIFICATE. 1,962
(2) THE INSURED HAS FAILED TO EXHAUST THE INSURER'S 1,964
INTERNAL REVIEW PROCESS. 1,965
(3) THE INSURED HAS PREVIOUSLY AFFORDED AN EXTERNAL REVIEW 1,967
FOR THE SAME DENIAL OF COVERAGE, AND NO NEW CLINICAL INFORMATION 1,968
HAS BEEN SUBMITTED TO THE INSURER. 1,969
(C)(1) AN INSURER MAY DENY A REQUEST FOR AN EXTERNAL 1,971
REVIEW IF IT IS REQUESTED LATER THAN SIXTY DAYS AFTER RECEIPT BY 1,972
THE INSURED OF NOTICE FROM THE SUPERINTENDENT OF INSURANCE UNDER 1,973
SECTION 3923.66 OF THE REVISED CODE THAT MAKING A DETERMINATION 1,974
REQUIRES THE RESOLUTION OF A MEDICAL ISSUE. AN EXTERNAL REVIEW 1,975
MAY BE REQUESTED BY THE INSURED, AN AUTHORIZED PERSON, THE 1,976
INSURED'S PROVIDER, OR A HEALTH CARE FACILITY RENDERING HEALTH 1,977
CARE SERVICE TO THE INSURED. THE INSURED MAY REQUEST A REVIEW 1,978
WITHOUT THE APPROVAL OF THE PROVIDER OR THE HEALTH CARE FACILITY 1,979
RENDERING THE HEALTH CARE SERVICE. THE PROVIDER OR HEALTH CARE 1,980
FACILITY MAY NOT REQUEST A REVIEW WITHOUT THE PRIOR CONSENT OF 1,981
THE INSURED.
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 1,983
EXCEPT THAT IF THE INSURED HAS A CONDITION THAT REQUIRES 1,984
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 1,985
ELECTRONIC MEANS. WHEN AN ORAL OR ELECTRONIC REQUEST FOR REVIEW 1,986
IS MADE, WRITTEN CONFIRMATION OF THE REQUEST MUST BE SUBMITTED TO 1,987
THE INSURER NOT LATER THAN FIVE DAYS AFTER THE REQUEST IS MADE. 1,988
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 1,990
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 1,991
THE INSURED'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING THE 1,992
44
HEALTH CARE SERVICE TO THE INSURED THAT THE PROPOSED SERVICE, 1,993
PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL COST THE 1,994
INSURED MORE THAN FIVE HUNDRED DOLLARS IF THE PROPOSED SERVICE IS 1,995
NOT COVERED BY THE INSURER. 1,996
(3) FOR AN EXPEDITED REVIEW, THE INSURED'S PROVIDER MUST 1,998
CERTIFY THAT THE INSURED'S CONDITION COULD, IN THE ABSENCE OF 1,999
IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE FOLLOWING: 2,000
(a) PLACING THE HEALTH OF THE INSURED OR, WITH RESPECT TO 2,002
A PREGNANT WOMAN, THE HEALTH OF THE INSURED OR THE UNBORN CHILD, 2,003
IN SERIOUS JEOPARDY; 2,004
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,006
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,008
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 2,010
SHALL INCLUDE ALL OF THE FOLLOWING: 2,011
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,013
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,014
SECTION 3901.80 OF THE REVISED CODE. 2,015
(2) EXCEPT AS PROVIDED IN DIVISIONS (D)(3) AND (4) OF THIS 2,017
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 2,018
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 2,019
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,020
FOLLOWING: 2,021
(a) THE INSURER OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,023
EMPLOYEE OF THE INSURER; 2,025
(b) THE INSURED, THE INSURED'S PROVIDER, OR THE PRACTICE 2,027
GROUP OF THE INSURED'S PROVIDER; 2,029
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 2,031
SERVICE REQUESTED BY THE INSURED WOULD BE PROVIDED; 2,032
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,034
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE INSURED. 2,035
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 2,037
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 2,038
CIRCUMSTANCES: 2,039
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 2,041
45
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO INSUREDS OF 2,042
THE INSURER. 2,043
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 2,045
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO INSUREDS OF 2,046
THE INSURER. 2,047
(c) THE CLINICAL PEER HAS A CONTRACTUAL RELATIONSHIP WITH 2,049
THE INSURER BUT WAS NOT INVOLVED WITH THE INSURER'S COVERAGE 2,050
DECISION.
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 2,052
INSURER FROM PAYING THE INDEPENDENT REVIEW ORGANIZATION FOR THE 2,053
CONDUCT OF THE REVIEW. 2,054
(5) AN INSURED SHALL NOT BE REQUIRED TO PAY FOR ANY PART 2,056
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 2,057
BY THE INSURER. 2,058
(6)(a) THE INSURER SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,061
ORGANIZATION CONDUCTING THE REVIEW A COPY OF THOSE RECORDS IN ITS
POSSESSION THAT ARE RELEVANT TO THE INSURED'S MEDICAL CONDITION 2,064
AND THE REVIEW.
RECORDS SHALL BE USED SOLELY FOR THE PURPOSE OF THIS 2,067
DIVISION. AT THE REQUEST OF THE INDEPENDENT REVIEW ORGANIZATION, 2,068
THE INSURER, INSURED, PROVIDER, OR HEALTH CARE FACILITY RENDERING 2,069
HEALTH CARE SERVICES TO THE INSURED SHALL PROVIDE ANY ADDITIONAL 2,070
INFORMATION THE INDEPENDENT REVIEW ORGANIZATION REQUESTS TO 2,071
COMPLETE THE REVIEW. A REQUEST FOR ADDITIONAL INFORMATION MAY BE 2,072
MADE IN WRITING, ORALLY, OR BY ELECTRONIC MEANS. THE INDEPENDENT 2,073
REVIEW ORGANIZATION SHALL SUBMIT THE REQUEST TO THE INSURED AND 2,074
INSURER. IF A REQUEST IS SUBMITTED ORALLY OR BY ELECTRONIC MEANS 2,075
TO AN INSURED OR INSURER, NOT LATER THAN FIVE DAYS AFTER THE 2,076
REQUEST IS SUBMITTED, THE INDEPENDENT REVIEW ORGANIZATION SHALL 2,077
PROVIDE WRITTEN CONFIRMATION OF THE REQUEST. IF THE REVIEW WAS 2,078
INITIATED BY A PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE 2,079
REQUEST SHALL BE SUBMITTED TO THE PROVIDER OR HEALTH CARE 2,080
FACILITY.
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 2,082
46
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 2,084
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. AN INDEPENDENT 2,085
REVIEW ORGANIZATION THAT DOES NOT MAKE A DECISION FOR THIS REASON 2,086
SHALL NOTIFY THE INSURED AND THE INSURER THAT A DECISION IS NOT 2,088
BEING MADE. THE NOTICE MAY BE MADE IN WRITING, ORALLY, OR BY 2,089
ELECTRONIC MEANS. AN ORAL OR ELECTRONIC NOTICE SHALL BE
CONFIRMED IN WRITING NOT LATER THAN FIVE DAYS AFTER THE ORAL OR 2,090
ELECTRONIC NOTICE IS MADE. IF THE REVIEW WAS INITIATED BY A 2,091
PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE NOTICE SHALL BE 2,092
SUBMITTED TO THE PROVIDER OR HEALTH CARE FACILITY. 2,093
(7) THE INSURER MAY ELECT TO COVER THE SERVICE REQUESTED 2,096
AND TERMINATE THE REVIEW. THE INSURER SHALL NOTIFY THE INSURED 2,097
AND ALL OTHER PARTIES INVOLVED WITH THE DECISION BY MAIL, OR WITH 2,098
THE CONSENT OR APPROVAL OF THE INSURED, BY ELECTRONIC MEANS. 2,099
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 2,101
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 2,102
THE FOLLOWING: 2,103
(a) INFORMATION SUBMITTED BY THE INSURER, THE INSURED, THE 2,105
INSURED'S PROVIDER, AND THE HEALTH CARE FACILITY RENDERING THE 2,106
HEALTH CARE SERVICE, INCLUDING THE FOLLOWING: 2,107
(i) THE INSURED'S MEDICAL RECORDS; 2,109
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 2,111
BY THE INSURER TO MAKE ITS DECISION. 2,112
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,114
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,115
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE 2,116
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 2,117
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 2,119
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 2,120
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 2,121
AND RESEARCH; 2,122
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,124
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 2,125
47
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY
RELEVANT NATIONAL MEDICAL SOCIETIES. 2,126
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,128
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,129
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,130
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A 2,131
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,132
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,133
COPY OF ITS DECISION TO THE INSURER AND THE INSURED. IF THE 2,134
INSURED'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING HEALTH 2,135
CARE SERVICES TO THE INSURED REQUESTED THE REVIEW, THE 2,136
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,137
DECISION TO THE INSURED'S PROVIDER OR THE HEALTH CARE FACILITY. 2,138
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 2,140
INCLUDE A DESCRIPTION OF THE INSURED'S CONDITION AND THE 2,141
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 2,142
CLINICAL RATIONALE FOR THE DECISION.
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 2,144
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 2,145
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 2,146
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 2,147
AND COST-EFFECTIVENESS.
(F) THE INSURER SHALL PROVIDE ANY COVERAGE DETERMINED BY 2,149
THE INDEPENDENT REVIEW ORGANIZATION'S DECISION TO BE MEDICALLY 2,150
NECESSARY, SUBJECT TO THE OTHER TERMS, LIMITATIONS, AND 2,151
CONDITIONS OF THE INSURED'S POLICY OR CERTIFICATE. 2,152
Sec. 3923.68. (A) EACH INSURER SHALL ESTABLISH A 2,154
REASONABLE EXTERNAL, INDEPENDENT REVIEW PROCESS TO EXAMINE THE 2,156
INSURER'S COVERAGE DECISIONS FOR INSUREDS WHO MEET ALL OF THE 2,157
FOLLOWING CRITERIA: 2,158
(1) THE INSURED HAS A TERMINAL CONDITION THAT, ACCORDING 2,160
TO THE CURRENT DIAGNOSIS OF THE INSURED'S PHYSICIAN, HAS A HIGH 2,161
PROBABILITY OF CAUSING DEATH WITHIN TWO YEARS. 2,162
(2) THE INSURED REQUESTS A REVIEW NOT LATER THAN SIXTY 2,164
48
DAYS AFTER RECEIPT BY THE INSURED OF NOTICE FROM THE 2,165
SUPERINTENDENT OF INSURANCE UNDER SECTION 3923.66 OF THE REVISED 2,166
CODE THAT MAKING A DETERMINATION REQUIRES RESOLUTION OF A MEDICAL 2,167
ISSUE.
(3) THE INSURED'S PHYSICIAN CERTIFIES THAT THE INSURED HAS 2,169
THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS SECTION AND 2,170
ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 2,171
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 2,173
IMPROVING THE CONDITION OF THE INSURED. 2,175
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,177
THE INSURED. 2,179
(c) THERE IS NO STANDARD THERAPY COVERED BY THE INSURER 2,181
THAT IS MORE BENEFICIAL THAN THERAPY DESCRIBED IN DIVISION (A)(4) 2,183
OF THIS SECTION. 2,184
(4) THE INSURED'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,186
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,187
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE INSURED, IN 2,188
THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR THE INSURED 2,189
HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A PREPONDERANCE OF 2,190
PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED WITH EFFECTIVE 2,191
CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,192
(5) THE INSURED HAS BEEN DENIED COVERAGE BY THE INSURER 2,194
FOR A DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY RECOMMENDED OR 2,195
REQUESTED PURSUANT TO DIVISION (A)(4) OF THIS SECTION, AND HAS 2,196
EXHAUSTED THE INSURER'S INTERNAL REVIEW PROCESS. 2,198
(6) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, FOR 2,200
WHICH COVERAGE HAS BEEN DENIED, WOULD BE A COVERED HEALTH CARE 2,201
SERVICE EXCEPT FOR THE INSURER'S DETERMINATION THAT THE DRUG, 2,202
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,203
INVESTIGATIONAL.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 2,205
THE INSURED'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 2,206
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 2,208
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. WHEN AN 2,209
49
ORAL OR ELECTRONIC REQUEST FOR REVIEW IS MADE, WRITTEN 2,210
CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED TO THE INSURER NOT 2,211
LATER THAN FIVE DAYS AFTER THE ORAL OR WRITTEN REQUEST IS
SUBMITTED. 2,212
(C) THE EXTERNAL, INDEPENDENT REVIEW PROCESS ESTABLISHED 2,214
BY AN INSURER SHALL MEET ALL OF THE FOLLOWING CRITERIA: 2,215
(1) EXCEPT AS PROVIDED IN DIVISION (E) OF THIS SECTION, 2,217
THE PROCESS SHALL AFFORD ALL INSUREDS WHO MEET THE CRITERIA SET 2,218
FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE THE 2,219
INSURER'S DECISION TO DENY COVERAGE OF THE RECOMMENDED OR 2,220
REQUESTED THERAPY REVIEWED UNDER THE PROCESS. EACH ELIGIBLE 2,222
INSURED SHALL BE NOTIFIED OF THAT OPPORTUNITY WITHIN THIRTY 2,223
BUSINESS DAYS AFTER THE INSURER DENIES COVERAGE. 2,224
(2) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,226
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,227
SECTION 3901.80 OF THE REVISED CODE. 2,228
THE INDEPENDENT REVIEW ORGANIZATION SHALL SELECT A PANEL TO 2,231
CONDUCT THE REVIEW, WHICH PANEL SHALL BE COMPOSED OF AT LEAST 2,232
THREE PHYSICIANS OR OTHER PROVIDERS WHO, THROUGH CLINICAL 2,233
EXPERIENCE IN THE PAST THREE YEARS, ARE EXPERTS IN THE TREATMENT 2,234
OF THE INSURED'S MEDICAL CONDITION AND KNOWLEDGEABLE ABOUT THE 2,235
RECOMMENDED OR REQUESTED THERAPY. 2,236
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,238
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,239
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,240
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,242
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF AN INSURED HAS 2,244
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL. 2,246
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,248
OR OTHER PROVIDER IF ONLY THE EXPERT PHYSICIAN OR OTHER PROVIDER 2,250
IS AVAILABLE FOR THE REVIEW. 2,251
(3) NEITHER THE INSURER NOR THE INSURED SHALL CHOOSE, OR 2,253
CONTROL THE CHOICE OF, THE PHYSICIAN OR OTHER PROVIDER EXPERTS. 2,254
50
(4) THE SELECTED EXPERTS, ANY HEALTH CARE FACILITY WITH 2,256
WHICH AN EXPERT IS AFFILIATED, AND THE INDEPENDENT REVIEW 2,257
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW SHALL NOT HAVE ANY 2,258
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,259
FOLLOWING:
(a) THE INSURER OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,261
EMPLOYEE OF THE INSURER; 2,263
(b) THE INSURED, THE INSURED'S PHYSICIAN, OR THE PRACTICE 2,265
GROUP OF THE INSURED'S PHYSICIAN; 2,267
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 2,269
REQUESTED THERAPY WOULD BE PROVIDED; 2,271
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,273
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 2,275
REQUESTED THERAPY.
HOWEVER, EXPERTS AFFILIATED WITH ACADEMIC MEDICAL CENTERS 2,278
WHO PROVIDE HEALTH CARE SERVICES TO INSUREDS OF THE INSURER MAY 2,280
SERVE AS EXPERTS ON THE REVIEW PANEL. FURTHER, EXPERTS WITH STAFF 2,281
PRIVILEGES AT A HEALTH CARE FACILITY THAT PROVIDES HEALTH CARE 2,282
SERVICES TO INSUREDS OF THE INSURER, AS WELL AS EXPERTS WHO HAVE 2,283
A CONTRACTUAL RELATIONSHIP WITH THE INSURER, BUT WHO WERE NOT 2,284
INVOLVED WITH THE INSURER'S DENIAL OF COVERAGE FOR THE THERAPY 2,285
UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. THESE 2,286
NONAFFILIATION PROVISIONS DO NOT PRECLUDE AN INSURER FROM PAYING 2,287
FOR THE EXPERTS' REVIEW, AS SPECIFIED IN DIVISION (C)(5) OF THIS 2,288
SECTION.
(5) INSUREDS SHALL NOT BE REQUIRED TO PAY FOR ANY PART OF 2,290
THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE BY 2,291
THE INSURER. 2,292
(6) THE INSURER SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,294
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW A COPY OF THOSE 2,295
RECORDS IN THE INSURER'S POSSESSION THAT ARE RELEVANT TO THE 2,296
INSURED'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL BE 2,297
DISCLOSED SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY 2,298
FOR THE PURPOSE OF THIS SECTION. AT THE REQUEST OF THE EXPERT 2,299
51
REVIEWERS, THE INSURER OR THE PHYSICIAN REQUESTING THE THERAPY 2,300
SHALL PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT 2,301
REVIEWERS REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS 2,302
NOT REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT 2,303
RECEIVED ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS 2,304
NECESSARY TO COMPLETE THE REVIEW.
(7)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,306
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,307
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,311
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,314
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,315
COPY OF ITS DECISION TO THE INSURER AND THE INSURED. IF THE 2,316
INSURED'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING HEALTH 2,317
CARE SERVICES TO THE INSURED REQUESTED THE REVIEW, THE 2,318
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,320
DECISION TO THE INSURED'S PROVIDER OR THE HEALTH CARE FACILITY. 2,321
(b) IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 2,323
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 2,324
(i) INFORMATION SUBMITTED BY THE INSURER, THE INSURED, AND 2,327
THE INSURED'S PHYSICIAN, INCLUDING THE INSURED'S MEDICAL RECORDS 2,328
AND THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED BY THE 2,329
INSURER TO REACH ITS COVERAGE DECISION; 2,330
(ii) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,332
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,333
ORGANIZATIONS;
(iii) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,335
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 2,336
RECOGNIZED MEDICAL EXPERTS; 2,337
(iv) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 2,339
MEDICAL SOCIETIES; 2,340
(v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 2,342
EFFECTIVENESS.
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,345
52
REVIEW ORGANIZATION WITH A PROFESSIONAL OPINION AS TO WHETHER 2,346
THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED 2,347
OR REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE 2,348
INSURED THAN STANDARD THERAPIES. 2,349
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 2,351
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 2,352
(a) A DESCRIPTION OF THE INSURED'S CONDITION; 2,354
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 2,356
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 2,358
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 2,360
TO BE MORE BENEFICIAL TO THE INSURED THAN STANDARD THERAPIES; 2,362
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 2,364
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 2,366
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 2,368
(d) A DESCRIPTION OF THE INSURED'S SUITABILITY TO RECEIVE 2,370
THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A TREATMENT 2,372
PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 2,374
(10) THE INDEPENDENT REVIEW ORGANIZATION SHALL PROVIDE THE 2,376
INSURER WITH THE OPINIONS OF THE EXPERTS. THE INSURER SHALL MAKE 2,377
THE EXPERTS' OPINIONS AVAILABLE TO THE INSURED AND THE INSURED'S 2,378
PHYSICIAN, UPON REQUEST. 2,379
(11) THE OPINION OF THE MAJORITY OF THE EXPERTS ON THE 2,381
PANEL, RENDERED PURSUANT TO DIVISION (C)(8) OF THIS SECTION, IS 2,382
BINDING ON THE INSURER WITH RESPECT TO THAT INSURED. IF THE 2,383
OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO 2,385
WHETHER THE THERAPY SHOULD BE COVERED, THE INSURER'S FINAL 2,386
DECISION SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A MAJORITY 2,387
OF THE EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE THERAPY, 2,388
THE INSURER MAY, IN ITS DISCRETION, COVER THE THERAPY. HOWEVER, 2,389
ANY COVERAGE PROVIDED PURSUANT TO DIVISION (C)(11) OF THIS 2,390
SECTION IS SUBJECT TO THE TERMS, LIMITATIONS, AND CONDITIONS OF 2,391
THE INSURED'S POLICY OR CERTIFICATE WITH THE INSURER. 2,392
(12) THE INSURER SHALL HAVE WRITTEN POLICIES DESCRIBING 2,394
THE EXTERNAL, INDEPENDENT REVIEW PROCESS. 2,395
53
(D) IF AN INSURER'S INITIAL DENIAL OF COVERAGE FOR A 2,397
THERAPY RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF 2,398
THIS SECTION IS BASED UPON AN EXTERNAL, INDEPENDENT REVIEW OF 2,399
THAT THERAPY MEETING THE REQUIREMENTS OF DIVISION (C) OF THIS 2,401
SECTION, THIS SECTION SHALL NOT BE A BASIS FOR REQUIRING A SECOND 2,402
EXTERNAL, INDEPENDENT REVIEW OF THE RECOMMENDED OR REQUESTED 2,403
THERAPY.
(E) AT ANY TIME DURING THE EXTERNAL, INDEPENDENT REVIEW 2,405
PROCESS, THE INSURER MAY ELECT TO COVER THE RECOMMENDED OR 2,406
REQUESTED HEALTH CARE SERVICE AND TERMINATE THE REVIEW. THE 2,408
INSURER SHALL NOTIFY THE INSURED AND ALL OTHER PARTIES INVOLVED 2,409
BY MAIL OR, WITH CONSENT OR APPROVAL OF THE INSURED, BY
ELECTRONIC MEANS. 2,410
(F) THE INSURER SHALL ANNUALLY FILE A CERTIFICATE WITH THE 2,412
SUPERINTENDENT OF INSURANCE CERTIFYING ITS COMPLIANCE WITH THE 2,413
REQUIREMENTS OF THIS SECTION. 2,414
Sec. 3923.681. (A) IF, AFTER NOTICE AND HEARING, THE 2,416
SUPERINTENDENT OF INSURANCE FINDS THAT AN INSURER HAS FAILED TO 2,418
COMPLY WITH SECTION 3923.66 OR 3923.67 OF THE REVISED CODE, THE 2,419
SUPERINTENDENT MAY SUSPEND OR REVOKE THE INSURER'S LICENSE TO 2,420
TRANSACT BUSINESS WITHIN THE STATE.
(B)(1) IN LIEU OF THE SUSPENSION OR REVOCATION OF A 2,423
LICENSE UNDER DIVISION (A) OF THIS SECTION, THE SUPERINTENDENT OF 2,424
INSURANCE, PURSUANT TO AN ADJUDICATION HEARING INITIATED AND 2,425
CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE, OR 2,427
BY CONSENT OF THE INSURER WITHOUT AN ADJUDICATION HEARING, MAY 2,428
LEVY AN ADMINISTRATIVE PENALTY. THE ADMINISTRATIVE PENALTY SHALL 2,429
BE IN AN AMOUNT DETERMINED BY THE SUPERINTENDENT, BUT THE 2,431
ADMINISTRATIVE PENALTY SHALL NOT EXCEED ONE HUNDRED THOUSAND 2,432
DOLLARS PER VIOLATION. ADDITIONALLY, THE SUPERINTENDENT MAY 2,433
REQUIRE THE INSURER TO CORRECT ANY DEFICIENCY THAT MAY BE THE 2,435
BASIS FOR THE SUSPENSION OR REVOCATION OF THE INSURER'S LICENSE. 2,436
ALL PENALTIES COLLECTED SHALL BE PAID INTO THE STATE TREASURY TO 2,438
THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING FUND. 2,439
54
(2) IF THE SUPERINTENDENT FOR ANY REASON HAS CAUSE TO 2,443
BELIEVE THAT ANY VIOLATION OF SECTION 3923.66 OR 3923.67 OF THE
REVISED CODE HAS OCCURRED OR IS THREATENED, THE SUPERINTENDENT 2,445
MAY GIVE NOTICE TO THE INSURER AND TO THE REPRESENTATIVES OR 2,447
OTHER PERSONS WHO APPEAR TO BE INVOLVED IN THE SUSPECTED 2,448
VIOLATION TO ARRANGE A CONFERENCE WITH THE SUSPECTED VIOLATORS OR 2,449
THEIR AUTHORIZED REPRESENTATIVES FOR THE PURPOSE OF ATTEMPTING TO 2,450
ASCERTAIN THE FACTS RELATING TO THE SUSPECTED VIOLATION, AND, IF 2,451
IT APPEARS THAT ANY VIOLATION HAS OCCURRED OR IS THREATENED, TO 2,452
ARRIVE AT AN ADEQUATE AND EFFECTIVE MEANS OF CORRECTING OR 2,453
PREVENTING THE VIOLATION.
PROCEEDINGS SHALL NOT BE COVERED BY ANY FORMAL PROCEDURAL 2,456
REQUIREMENTS, AND MAY BE CONDUCTED IN THE MANNER THE 2,457
SUPERINTENDENT MAY CONSIDER APPROPRIATE UNDER THE CIRCUMSTANCES. 2,458
(3)(a) THE SUPERINTENDENT MAY ISSUE AN ORDER DIRECTING AN 2,460
INSURER OR A REPRESENTATIVE OF THE INSURER TO CEASE AND DESIST 2,461
FROM ENGAGING IN ANY ACT OR PRACTICE IN VIOLATION OF SECTION 2,463
3923.67 OR 3923.68 OF THE REVISED CODE. WITHIN THIRTY DAYS AFTER 2,464
SERVICE OF THE ORDER TO CEASE AND DESIST, THE RESPONDENT MAY 2,465
REQUEST A HEARING ON THE QUESTION OF WHETHER ACTS OR PRACTICES IN 2,467
VIOLATION OF THOSE SECTIONS HAVE OCCURRED. SUCH HEARINGS SHALL
BE CONDUCTED IN ACCORDANCE WITH CHAPTER 119. OF THE REVISED CODE 2,469
AND JUDICIAL REVIEW SHALL BE AVAILABLE AS PROVIDED BY THAT 2,470
CHAPTER.
(b) IF THE SUPERINTENDENT HAS REASONABLE CAUSE TO BELIEVE 2,472
THAT AN ORDER HAS BEEN VIOLATED IN WHOLE OR IN PART, THE 2,474
SUPERINTENDENT MAY REQUEST THE ATTORNEY GENERAL TO COMMENCE AND 2,475
PROSECUTE ANY APPROPRIATE ACTION OR PROCEEDING IN THE NAME OF THE 2,476
STATE AGAINST THE VIOLATORS IN THE COURT OF COMMON PLEAS OF 2,478
FRANKLIN COUNTY. THE COURT IN ANY SUCH ACTION OR PROCEEDING MAY 2,479
LEVY CIVIL PENALTIES, NOT TO EXCEED ONE HUNDRED THOUSAND DOLLARS 2,480
PER VIOLATION, IN ADDITION TO ANY OTHER APPROPRIATE RELIEF, 2,481
INCLUDING REQUIRING A VIOLATOR TO PAY THE EXPENSES REASONABLY 2,482
INCURRED BY THE SUPERINTENDENT IN ENFORCING THE ORDER. THE 2,483
55
PENALTIES AND FEES COLLECTED SHALL BE PAID INTO THE STATE 2,484
TREASURY TO THE CREDIT OF THE DEPARTMENT OF INSURANCE OPERATING 2,485
FUND.
Sec. 3923.69. NOTHING IN SECTIONS 3923.66 TO 3923.68 OF 2,487
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 2,489
AGAINST ANY OF THE FOLLOWING:
(A) AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO 2,493
EMPLOYEES THROUGH AN INSURER;
(B) A CLINICAL PEER, MEDICAL EXPERT, OR INDEPENDENT REVIEW 2,496
ORGANIZATION THAT PARTICIPATES IN AN EXTERNAL REVIEW UNDER 2,497
SECTION 3923.67 OR 3923.68 OF THE REVISED CODE; 2,498
(C) AN INSURER THAT PROVIDES COVERAGE FOR BENEFITS 2,502
PURSUANT TO SECTION 3923.67 OR 3923.68 OF THE REVISED CODE. 2,503
Sec. 3923.70. CONSISTENT WITH THE RULES OF EVIDENCE, A 2,506
WRITTEN DECISION OR OPINION PREPARED BY AN INDEPENDENT REVIEW 2,507
ORGANIZATION UNDER SECTION 3923.67 OR 3923.68 OF THE REVISED CODE 2,508
SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO THE COVERAGE 2,509
DECISION THAT WAS THE SUBJECT OF THE DECISION OR OPINION. THE 2,510
INDEPENDENT REVIEW ORGANIZATION'S DECISION OR OPINION SHALL BE 2,511
PRESUMED TO BE A SCIENTIFICALLY VALID AND ACCURATE DESCRIPTION OF 2,512
THE STATE OF MEDICAL KNOWLEDGE AT THE TIME IT WAS WRITTEN. 2,513
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 2,516
ACTION RELATED TO AN INSURER'S DECISION INVOLVING AN 2,517
INVESTIGATIONAL OR EXPERIMENTAL DRUG, DEVICE, OR TREATMENT MAY
INTRODUCE INTO EVIDENCE ANY APPLICABLE MEDICARE REIMBURSEMENT 2,518
STANDARDS ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL SECURITY 2,520
ACT," 49 STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. 2,521
Sec. 3923.75. (A) AS USED IN SECTIONS 3923.75 TO 3923.79 2,523
OF THE REVISED CODE: 2,524
(1) "CLINICAL PEER" AND "PHYSICIAN" HAVE THE SAME MEANINGS 2,526
AS IN SECTION 1751.77 OF THE REVISED CODE. 2,527
(2) "AUTHORIZED PERSON" MEANS A PARENT, GUARDIAN, OR OTHER 2,529
PERSON AUTHORIZED TO ACT ON BEHALF OF A PLAN MEMBER WITH RESPECT 2,530
TO HEALTH CARE DECISIONS. 2,531
56
(B) SECTIONS 3923.75 TO 3923.79 OF THE REVISED CODE DO NOT 2,533
APPLY TO ANY PUBLIC EMPLOYEE BENEFIT PLAN COVERING ONLY ACCIDENT, 2,535
CREDIT, DENTAL, DISABILITY INCOME, LONG-TERM CARE, HOSPITAL 2,536
INDEMNITY, MEDICARE SUPPLEMENT, MEDICARE, TRICARE, SPECIFIED 2,537
DISEASE, OR VISION CARE; COVERAGE ISSUED AS A SUPPLEMENT TO 2,538
LIABILITY INSURANCE; INSURANCE ARISING OUT OF WORKERS' 2,539
COMPENSATION OR SIMILAR LAW; AUTOMOBILE MEDICAL PAYMENT 2,540
INSURANCE; OR INSURANCE UNDER WHICH BENEFITS ARE PAYABLE WITH OR 2,541
WITHOUT REGARD TO FAULT AND WHICH IS STATUTORILY REQUIRED TO BE 2,542
CONTAINED IN ANY LIABILITY INSURANCE POLICY OR EQUIVALENT 2,543
SELF-INSURANCE.
(C) THE SUPERINTENDENT OF INSURANCE SHALL ESTABLISH AND 2,545
MAINTAIN A SYSTEM FOR RECEIVING AND REVIEWING REQUESTS FOR REVIEW 2,547
FROM PLAN MEMBERS WHO HAVE BEEN DENIED COVERAGE OF A HEALTH CARE 2,548
SERVICE ON THE GROUNDS THAT THE SERVICE IS NOT A SERVICE COVERED 2,549
UNDER THE TERMS OF THE PUBLIC EMPLOYEE BENEFIT PLAN. 2,550
ON RECEIPT OF A WRITTEN REQUEST FROM A PLAN MEMBER OR 2,552
AUTHORIZED PERSON, THE SUPERINTENDENT SHALL CONSIDER WHETHER THE 2,553
HEALTH CARE SERVICE IS A SERVICE COVERED UNDER THE TERMS OF THE 2,554
PLAN, EXCEPT THAT THE SUPERINTENDENT SHALL NOT CONDUCT A REVIEW 2,556
UNDER THIS SECTION UNLESS THE PLAN MEMBER HAS EXHAUSTED THE 2,557
PLAN'S INTERNAL REVIEW PROCESS. THE PLAN AND THE PLAN MEMBER OR 2,558
AUTHORIZED PERSON SHALL PROVIDE THE SUPERINTENDENT WITH ANY 2,559
INFORMATION REQUIRED BY THE SUPERINTENDENT THAT IS IN THEIR 2,560
POSSESSION AND IS GERMANE TO THE REVIEW.
UNLESS THE SUPERINTENDENT IS NOT ABLE TO DO SO BECAUSE 2,562
MAKING THE DETERMINATION REQUIRES RESOLUTION OF A MEDICAL ISSUE, 2,563
THE SUPERINTENDENT SHALL DETERMINE WHETHER THE HEALTH CARE 2,564
SERVICE AT ISSUE IS A SERVICE COVERED UNDER THE TERMS OF THE 2,565
PLAN. THE SUPERINTENDENT SHALL NOTIFY THE PLAN MEMBER AND THE 2,566
PLAN OF ITS DETERMINATION OR THAT IT IS NOT ABLE TO MAKE A 2,567
DETERMINATION BECAUSE THE DETERMINATION REQUIRES THE RESOLUTION 2,568
OF A MEDICAL ISSUE.
IF THE SUPERINTENDENT NOTIFIES THE PLAN THAT MAKING THE 2,570
57
DETERMINATION REQUIRES THE RESOLUTION OF A MEDICAL ISSUE, THE 2,571
PLAN SHALL AFFORD THE PLAN MEMBER AN OPPORTUNITY FOR EXTERNAL 2,572
REVIEW UNDER SECTION 3923.76 OR 3923.77 OF THE REVISED CODE. IF 2,573
THE SUPERINTENDENT NOTIFIES THE PLAN THAT THE HEALTH CARE SERVICE 2,574
IS NOT A COVERED SERVICE, THE PLAN IS NOT REQUIRED TO COVER THE 2,575
SERVICE OR AFFORD THE PLAN MEMBER AN EXTERNAL REVIEW. 2,576
Sec. 3923.76. (A) EXCEPT AS PROVIDED IN DIVISIONS (B) AND 2,579
(C) OF THIS SECTION, A PUBLIC EMPLOYEE BENEFIT PLAN SHALL AFFORD 2,580
A PLAN MEMBER AN OPPORTUNITY FOR AN EXTERNAL REVIEW OF A 2,582
COVERAGE DENIAL WHEN REQUESTED BY THE PLAN MEMBER OR AUTHORIZED 2,583
PERSON, IF BOTH OF THE FOLLOWING ARE THE CASE:
(1) THE PLAN HAS DENIED, REDUCED, OR TERMINATED COVERAGE 2,585
FOR WHAT WOULD BE A COVERED HEALTH CARE SERVICE EXCEPT THAT THE 2,586
PLAN HAS DETERMINED THAT THE HEALTH CARE SERVICE IS NOT MEDICALLY 2,587
NECESSARY.
(2) EXCEPT IN THE CASE OF EXPEDITED REVIEW, THE PROPOSED 2,590
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 2,591
COST THE PLAN MEMBER MORE THAN FIVE HUNDRED DOLLARS IF THE 2,592
PROPOSED SERVICE IS NOT COVERED BY THE PLAN. 2,593
EXTERNAL REVIEW SHALL BE CONDUCTED IN ACCORDANCE WITH THIS 2,595
SECTION, EXCEPT THAT IF A PLAN MEMBER WITH A TERMINAL CONDITION 2,596
MEETS ALL OF THE CRITERIA OF DIVISION (A) OF SECTION 3923.77 OF 2,597
THE REVISED CODE, AN EXTERNAL REVIEW SHALL BE CONDUCTED UNDER 2,599
THAT SECTION. 2,600
(B) A PLAN MEMBER NEED NOT BE AFFORDED A REVIEW UNDER THIS 2,602
SECTION IN ANY OF THE FOLLOWING CIRCUMSTANCES: 2,604
(1) THE SUPERINTENDENT OF INSURANCE HAS DETERMINED UNDER 2,606
SECTION 3923.75 OF THE REVISED CODE THAT THE HEALTH CARE SERVICE 2,607
IS NOT A SERVICE COVERED UNDER THE TERMS OF THE PLAN. 2,608
(2) THE PLAN MEMBER HAS FAILED TO EXHAUST THE PLAN'S 2,610
INTERNAL REVIEW PROCESS. 2,611
(3) THE PLAN MEMBER HAS PREVIOUSLY BEEN AFFORDED AN 2,613
EXTERNAL REVIEW FOR THE SAME DENIAL OF COVERAGE, AND NO NEW 2,614
CLINICAL INFORMATION HAS BEEN SUBMITTED TO THE PLAN. 2,615
58
(C)(1) A PLAN MAY DENY A REQUEST FOR AN EXTERNAL REVIEW IF 2,617
IT IS REQUESTED LATER THAN SIXTY DAYS AFTER RECEIPT BY THE PLAN 2,618
MEMBER OF NOTICE FROM THE SUPERINTENDENT OF INSURANCE UNDER 2,619
SECTION 3923.75 OF THE REVISED CODE THAT MAKING THE DETERMINATION 2,620
REQUIRES THE RESOLUTION OF A MEDICAL ISSUE. AN EXTERNAL REVIEW 2,622
MAY BE REQUESTED BY THE PLAN MEMBER, AN AUTHORIZED PERSON, THE 2,623
PLAN MEMBER'S PROVIDER, OR A HEALTH CARE FACILITY RENDERING 2,624
HEALTH CARE SERVICE TO THE PLAN MEMBER. THE PLAN MEMBER MAY 2,625
REQUEST A REVIEW WITHOUT THE APPROVAL OF THE PROVIDER OR THE 2,626
HEALTH CARE FACILITY RENDERING THE HEALTH CARE SERVICE. THE 2,627
PROVIDER OR HEALTH CARE FACILITY MAY NOT REQUEST A REVIEW WITHOUT 2,628
THE PRIOR CONSENT OF THE PLAN MEMBER.
(2) AN EXTERNAL REVIEW MUST BE REQUESTED IN WRITING, 2,630
EXCEPT THAT IF THE PLAN MEMBER HAS A CONDITION THAT REQUIRES 2,631
EXPEDITED REVIEW, THE REVIEW MAY BE REQUESTED ORALLY OR BY 2,632
ELECTRONIC MEANS. WHEN AN ORAL OR ELECTRONIC REQUEST FOR REVIEW 2,633
IS MADE, WRITTEN CONFIRMATION OF THE REQUEST MUST BE SUBMITTED TO 2,634
THE PLAN NOT LATER THAN FIVE DAYS AFTER THE REQUEST IS MADE. 2,635
EXCEPT IN THE CASE OF AN EXPEDITED REVIEW, A REQUEST FOR AN 2,637
EXTERNAL REVIEW MUST BE ACCOMPANIED BY WRITTEN CERTIFICATION FROM 2,638
THE PLAN MEMBER'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING 2,639
THE HEALTH CARE SERVICE TO THE PLAN MEMBER THAT THE PROPOSED 2,640
SERVICE, PLUS ANY ANCILLARY SERVICES AND FOLLOW-UP CARE, WILL 2,641
COST THE PLAN MEMBER MORE THAN FIVE HUNDRED DOLLARS IF THE 2,642
PROPOSED SERVICE IS NOT COVERED BY THE PLAN. 2,643
(3) FOR AN EXPEDITED REVIEW, THE PLAN MEMBER'S PROVIDER 2,645
MUST CERTIFY THAT THE PLAN MEMBER'S CONDITION COULD, IN THE 2,646
ABSENCE OF IMMEDIATE MEDICAL ATTENTION, RESULT IN ANY OF THE 2,647
FOLLOWING:
(a) PLACING THE HEALTH OF THE PLAN MEMBER OR, WITH RESPECT 2,649
TO A PREGNANT WOMAN, THE HEALTH OF THE PLAN MEMBER OR THE UNBORN 2,651
CHILD, IN SERIOUS JEOPARDY; 2,652
(b) SERIOUS IMPAIRMENT TO BODILY FUNCTIONS; 2,654
(c) SERIOUS DYSFUNCTION OF ANY BODILY ORGAN OR PART. 2,656
59
(D) THE PROCEDURES USED IN CONDUCTING AN EXTERNAL REVIEW 2,658
SHALL INCLUDE ALL OF THE FOLLOWING: 2,659
(1) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,661
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,662
SECTION 3901.80 OF THE REVISED CODE. 2,663
(2) EXCEPT AS PROVIDED IN DIVISIONS (D)(3) AND (4) OF THIS 2,665
SECTION, NEITHER THE CLINICAL PEER NOR ANY HEALTH CARE FACILITY 2,666
WITH WHICH THE CLINICAL PEER IS AFFILIATED SHALL HAVE ANY 2,667
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,668
FOLLOWING: 2,669
(a) THE PLAN OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,671
EMPLOYEE OF THE PLAN; 2,673
(b) THE PLAN MEMBER, THE PLAN MEMBER'S PROVIDER, OR THE 2,675
PRACTICE GROUP OF THE PLAN MEMBER'S PROVIDER; 2,677
(c) THE HEALTH CARE FACILITY AT WHICH THE HEALTH CARE 2,679
SERVICE REQUESTED BY THE PLAN MEMBER WOULD BE PROVIDED; 2,681
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,683
DEVICE, PROCEDURE, OR THERAPY PROPOSED FOR THE PLAN MEMBER. 2,685
(3) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT A 2,687
CLINICAL PEER FROM CONDUCTING A REVIEW UNDER ANY OF THE FOLLOWING 2,688
CIRCUMSTANCES: 2,689
(a) THE CLINICAL PEER IS AFFILIATED WITH AN ACADEMIC 2,691
MEDICAL CENTER THAT PROVIDES HEALTH CARE SERVICES TO MEMBERS OF 2,693
THE PLAN. 2,694
(b) THE CLINICAL PEER HAS STAFF PRIVILEGES AT A HEALTH 2,696
CARE FACILITY THAT PROVIDES HEALTH CARE SERVICES TO MEMBERS OF 2,698
THE PLAN. 2,699
(c) THE CLINICAL PEER HAS A CONTRACTUAL RELATIONSHIP WITH 2,701
THE PLAN BUT WAS NOT INVOLVED WITH THE PLAN'S COVERAGE DECISION. 2,703
(4) DIVISION (D)(2) OF THIS SECTION DOES NOT PROHIBIT THE 2,705
PLAN FROM PAYING THE INDEPENDENT REVIEW ORGANIZATION FOR THE 2,706
CONDUCT OF THE REVIEW. 2,707
(5) A PLAN MEMBER SHALL NOT BE REQUIRED TO PAY FOR ANY 2,709
PART OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE 2,710
60
BORNE BY THE PLAN. 2,711
(6)(a) THE PLAN SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,713
ORGANIZATION CONDUCTING THE REVIEW A COPY OF THOSE RECORDS IN ITS 2,715
POSSESSION THAT ARE RELEVANT TO THE PLAN MEMBER'S MEDICAL 2,716
CONDITION AND THE REVIEW. 2,717
RECORDS SHALL BE USED SOLELY FOR THE PURPOSE OF THIS 2,720
DIVISION. AT THE REQUEST OF THE INDEPENDENT REVIEW ORGANIZATION, 2,721
THE PLAN, PLAN MEMBER, PROVIDER, OR HEALTH CARE FACILITY 2,722
RENDERING HEALTH CARE SERVICES TO THE PLAN MEMBER SHALL PROVIDE 2,723
ANY ADDITIONAL INFORMATION THE INDEPENDENT REVIEW ORGANIZATION 2,724
REQUESTS TO COMPLETE THE REVIEW. A REQUEST FOR ADDITIONAL
INFORMATION MAY BE MADE IN WRITING, ORALLY, OR BY ELECTRONIC 2,725
MEANS. THE INDEPENDENT REVIEW ORGANIZATION SHALL SUBMIT THE 2,726
REQUEST TO THE PLAN MEMBER AND THE PLAN. IF A REQUEST IS 2,727
SUBMITTED ORALLY OR BY ELECTRONIC MEANS TO A PLAN MEMBER OR PLAN, 2,728
NOT LATER THAN FIVE DAYS AFTER THE REQUEST IS SUBMITTED, THE 2,729
INDEPENDENT REVIEW ORGANIZATION SHALL PROVIDE WRITTEN 2,730
CONFIRMATION OF THE REQUEST. IF THE REVIEW WAS INITIATED BY A 2,731
PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE REQUEST SHALL BE 2,732
SUBMITTED TO THE PROVIDER OR HEALTH CARE FACILITY. 2,733
(b) AN INDEPENDENT REVIEW ORGANIZATION IS NOT REQUIRED TO 2,735
MAKE A DECISION IF IT HAS NOT RECEIVED ANY REQUESTED INFORMATION 2,737
THAT IT CONSIDERS NECESSARY TO COMPLETE A REVIEW. AN INDEPENDENT 2,738
REVIEW ORGANIZATION THAT DOES NOT MAKE A DECISION FOR THIS REASON 2,739
SHALL NOTIFY THE PLAN MEMBER AND THE PLAN THAT A DECISION IS NOT 2,741
BEING MADE. THE NOTICE MAY BE MADE IN WRITING, ORALLY, OR BY 2,742
ELECTRONIC MEANS. AN ORAL OR ELECTRONIC NOTICE SHALL BE
CONFIRMED IN WRITING NOT LATER THAN FIVE DAYS AFTER THE ORAL OR 2,743
ELECTRONIC NOTICE IS MADE. IF THE REVIEW WAS INITIATED BY A 2,744
PROVIDER OR HEALTH CARE FACILITY, A COPY OF THE NOTICE SHALL BE 2,745
SUBMITTED TO THE PROVIDER OR HEALTH CARE FACILITY. 2,746
(7) THE PLAN MAY ELECT TO COVER THE SERVICE REQUESTED AND 2,749
TERMINATE THE REVIEW. THE PLAN SHALL NOTIFY THE PLAN MEMBER AND 2,750
ALL OTHER PARTIES INVOLVED WITH THE DECISION BY MAIL, OR WITH THE 2,751
61
CONSENT OR APPROVAL OF THE PLAN MEMBER, BY ELECTRONIC MEANS. 2,752
(8) IN MAKING ITS DECISION, AN INDEPENDENT REVIEW 2,754
ORGANIZATION CONDUCTING THE REVIEW SHALL TAKE INTO ACCOUNT ALL OF 2,755
THE FOLLOWING: 2,756
(a) INFORMATION SUBMITTED BY THE PLAN, THE PLAN MEMBER, 2,758
THE PLAN MEMBER'S PROVIDER, AND THE HEALTH CARE FACILITY 2,760
RENDERING THE HEALTH CARE SERVICE, INCLUDING THE FOLLOWING: 2,761
(i) THE PLAN MEMBER'S MEDICAL RECORDS; 2,763
(ii) THE STANDARDS, CRITERIA, AND CLINICAL RATIONALE USED 2,765
BY THE PLAN TO MAKE ITS DECISION. 2,767
(b) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,769
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,771
ORGANIZATIONS, INCLUDING THE NATIONAL INSTITUTES OF HEALTH OR ANY 2,772
BOARD RECOGNIZED BY THE NATIONAL INSTITUTES OF HEALTH, THE 2,773
NATIONAL CANCER INSTITUTE, THE NATIONAL ACADEMY OF SCIENCES, THE 2,774
UNITED STATES FOOD AND DRUG ADMINISTRATION, THE HEALTH CARE 2,776
FINANCING ADMINISTRATION OF THE UNITED STATES DEPARTMENT OF 2,777
HEALTH AND HUMAN SERVICES, AND THE AGENCY FOR HEALTH CARE POLICY 2,778
AND RESEARCH; 2,779
(c) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,781
SCIENTIFIC LITERATURE, PUBLISHED OPINIONS OF NATIONALLY 2,783
RECOGNIZED MEDICAL EXPERTS, AND CLINICAL GUIDELINES ADOPTED BY 2,784
RELEVANT NATIONAL MEDICAL SOCIETIES. 2,785
(9)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,787
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,788
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,789
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A 2,790
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,791
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,792
COPY OF ITS DECISION TO THE PLAN AND THE PLAN MEMBER. IF THE 2,793
PLAN MEMBER'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING 2,794
HEALTH CARE SERVICES TO THE PLAN MEMBER REQUESTED THE REVIEW, THE 2,795
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,796
DECISION TO THE PLAN MEMBER'S PROVIDER OR THE HEALTH CARE 2,797
62
FACILITY.
(b) THE INDEPENDENT REVIEW ORGANIZATION'S DECISION SHALL 2,799
INCLUDE A DESCRIPTION OF THE PLAN MEMBER'S CONDITION AND THE 2,801
PRINCIPAL REASONS FOR THE DECISION AND AN EXPLANATION OF THE 2,803
CLINICAL RATIONALE FOR THE DECISION.
(E) THE INDEPENDENT REVIEW ORGANIZATION SHALL BASE ITS 2,805
DECISION ON THE INFORMATION SUBMITTED UNDER DIVISION (D)(8) OF 2,806
THIS SECTION. IN MAKING ITS DECISION, THE INDEPENDENT REVIEW 2,807
ORGANIZATION SHALL CONSIDER SAFETY, EFFICACY, APPROPRIATENESS, 2,809
AND COST-EFFECTIVENESS.
(F) THE PLAN SHALL PROVIDE ANY COVERAGE DETERMINED BY THE 2,811
INDEPENDENT REVIEW ORGANIZATION'S DECISION TO BE MEDICALLY 2,812
NECESSARY, SUBJECT TO THE OTHER TERMS, LIMITATIONS, AND 2,814
CONDITIONS OF THE PLAN.
Sec. 3923.77. (A) EACH PUBLIC EMPLOYEE BENEFIT PLAN SHALL 2,816
ESTABLISH A REASONABLE EXTERNAL REVIEW PROCESS TO EXAMINE THE 2,818
PLAN'S COVERAGE DECISIONS FOR PLAN MEMBERS WHO MEET ALL OF THE 2,819
FOLLOWING CRITERIA: 2,820
(1) THE PLAN MEMBER HAS A TERMINAL CONDITION THAT, 2,822
ACCORDING TO THE CURRENT DIAGNOSIS OF THE PLAN MEMBER'S 2,823
PHYSICIAN, HAS A HIGH PROBABILITY OF CAUSING DEATH WITHIN TWO 2,824
YEARS.
(2) THE PLAN MEMBER REQUESTS A REVIEW NOT LATER THAN SIXTY 2,826
DAYS AFTER RECEIPT BY THE PLAN MEMBER OF NOTICE FROM THE 2,827
SUPERINTENDENT OF INSURANCE UNDER SECTION 3923.75 OF THE REVISED 2,828
CODE THAT MAKING A DETERMINATION REQUIRES RESOLUTION OF A MEDICAL 2,829
ISSUE.
(3) THE PLAN MEMBER'S PHYSICIAN CERTIFIES THAT THE PLAN 2,831
MEMBER HAS THE CONDITION DESCRIBED IN DIVISION (A)(1) OF THIS 2,832
SECTION AND ANY OF THE FOLLOWING SITUATIONS ARE APPLICABLE: 2,833
(a) STANDARD THERAPIES HAVE NOT BEEN EFFECTIVE IN 2,835
IMPROVING THE CONDITION OF THE PLAN MEMBER. 2,837
(b) STANDARD THERAPIES ARE NOT MEDICALLY APPROPRIATE FOR 2,839
THE PLAN MEMBER. 2,841
63
(c) THERE IS NO STANDARD THERAPY COVERED BY THE PLAN THAT 2,843
IS MORE BENEFICIAL THAN THERAPY DESCRIBED IN DIVISION (A)(4) OF 2,845
THIS SECTION. 2,846
(4) THE PLAN MEMBER'S PHYSICIAN HAS RECOMMENDED A DRUG, 2,848
DEVICE, PROCEDURE, OR OTHER THERAPY THAT THE PHYSICIAN CERTIFIES, 2,849
IN WRITING, IS LIKELY TO BE MORE BENEFICIAL TO THE PLAN MEMBER, 2,850
IN THE PHYSICIAN'S OPINION, THAN STANDARD THERAPIES, OR THE PLAN 2,851
MEMBER HAS REQUESTED A THERAPY THAT HAS BEEN FOUND IN A 2,852
PREPONDERANCE OF PEER-REVIEWED PUBLISHED STUDIES TO BE ASSOCIATED 2,853
WITH EFFECTIVE CLINICAL OUTCOMES FOR THE SAME CONDITION. 2,854
(5) THE PLAN MEMBER HAS BEEN DENIED COVERAGE BY THE PLAN 2,856
FOR A DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY RECOMMENDED OR 2,857
REQUESTED PURSUANT TO DIVISION (A)(4) OF THIS SECTION, AND HAS 2,858
EXHAUSTED ALL INTERNAL APPEALS. 2,859
(6) THE DRUG, DEVICE, PROCEDURE, OR OTHER THERAPY, FOR 2,861
WHICH COVERAGE HAS BEEN DENIED, WOULD BE A COVERED HEALTH CARE 2,862
SERVICE EXCEPT FOR THE PLAN'S DETERMINATION THAT THE DRUG, 2,863
DEVICE, PROCEDURE, OR OTHER THERAPY IS EXPERIMENTAL OR 2,864
INVESTIGATIONAL.
(B) A REVIEW SHALL BE REQUESTED IN WRITING, EXCEPT THAT IF 2,866
THE PLAN MEMBER'S PHYSICIAN DETERMINES THAT A THERAPY WOULD BE 2,867
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED, THE 2,869
REVIEW MAY BE REQUESTED ORALLY OR BY ELECTRONIC MEANS. WHEN AN 2,870
ORAL OR ELECTRONIC REQUEST FOR REVIEW IS MADE, WRITTEN 2,871
CONFIRMATION OF THE REQUEST SHALL BE SUBMITTED TO THE PLAN NOT 2,872
LATER THAN FIVE DAYS AFTER THE ORAL OR WRITTEN REQUEST IS
SUBMITTED. FOR AN EXPEDITED REVIEW, THE PLAN MEMBER'S PROVIDER 2,873
MUST CERTIFY THAT THE REQUESTED OR RECOMMENDED THERAPY WOULD BE 2,874
SIGNIFICANTLY LESS EFFECTIVE IF NOT PROMPTLY INITIATED. 2,875
(C) THE EXTERNAL REVIEW PROCESS ESTABLISHED BY A PLAN 2,878
SHALL MEET ALL OF THE FOLLOWING CRITERIA:
(1) EXCEPT AS PROVIDED IN DIVISION (E) OF THIS SECTION, 2,880
THE PROCESS SHALL AFFORD ALL PLAN MEMBERS WHO MEET THE CRITERIA 2,881
SET FORTH IN DIVISION (A) OF THIS SECTION THE OPPORTUNITY TO HAVE 2,882
64
THE PLAN'S DECISION TO DENY COVERAGE OF THE RECOMMENDED OR 2,883
REQUESTED THERAPY REVIEWED UNDER THE PROCESS. EACH ELIGIBLE PLAN 2,885
MEMBER SHALL BE NOTIFIED OF THAT OPPORTUNITY WITHIN THIRTY 2,886
BUSINESS DAYS AFTER THE PLAN DENIES COVERAGE. 2,887
(2) THE REVIEW SHALL BE CONDUCTED BY AN INDEPENDENT REVIEW 2,889
ORGANIZATION ASSIGNED BY THE SUPERINTENDENT OF INSURANCE UNDER 2,890
SECTION 3901.80 OF THE REVISED CODE. THE INDEPENDENT REVIEW 2,892
ORGANIZATION SHALL SELECT A PANEL TO CONDUCT THE REVIEW, WHICH 2,893
PANEL SHALL BE COMPOSED OF AT LEAST THREE PHYSICIANS OR OTHER 2,894
PROVIDERS WHO, THROUGH CLINICAL EXPERIENCE IN THE PAST THREE 2,895
YEARS, ARE EXPERTS IN THE TREATMENT OF THE PLAN MEMBER'S MEDICAL 2,896
CONDITION AND KNOWLEDGEABLE ABOUT THE RECOMMENDED OR REQUESTED 2,897
THERAPY. IF THE INDEPENDENT REVIEW ORGANIZATION RETAINED BY THE 2,898
PLAN IS AN ACADEMIC MEDICAL CENTER, THE PANEL MAY INCLUDE EXPERTS 2,899
AFFILIATED WITH OR EMPLOYED BY THE ACADEMIC MEDICAL CENTER. 2,900
IN EITHER OF THE FOLLOWING CIRCUMSTANCES, AN EXCEPTION MAY 2,902
BE MADE TO THE REQUIREMENT THAT THE REVIEW BE CONDUCTED BY AN 2,903
EXPERT PANEL COMPOSED OF A MINIMUM OF THREE PHYSICIANS OR OTHER 2,904
PROVIDERS:
(a) A REVIEW MAY BE CONDUCTED BY AN EXPERT PANEL COMPOSED 2,906
OF ONLY TWO PHYSICIANS OR OTHER PROVIDERS IF A PLAN MEMBER HAS 2,907
CONSENTED IN WRITING TO A REVIEW BY THE SMALLER PANEL. 2,908
(b) A REVIEW MAY BE CONDUCTED BY A SINGLE EXPERT PHYSICIAN 2,910
OR OTHER PROVIDER IF ONLY THE EXPERT PHYSICIAN OR OTHER PROVIDER 2,911
IS AVAILABLE FOR THE REVIEW. 2,912
(3) NEITHER THE PLAN NOR THE PLAN MEMBER SHALL CHOOSE, OR 2,914
CONTROL THE CHOICE OF, THE PHYSICIAN OR OTHER PROVIDER EXPERTS. 2,915
(4) THE SELECTED EXPERTS, ANY HEALTH CARE FACILITY WITH 2,917
WHICH AN EXPERT IS AFFILIATED, AND THE INDEPENDENT REVIEW 2,918
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW SHALL NOT HAVE ANY 2,919
PROFESSIONAL, FAMILIAL, OR FINANCIAL AFFILIATION WITH ANY OF THE 2,920
FOLLOWING:
(a) THE PLAN OR ANY OFFICER, DIRECTOR, OR MANAGERIAL 2,922
EMPLOYEE OF THE PLAN; 2,923
65
(b) THE PLAN MEMBER, THE PLAN MEMBER'S PHYSICIAN, OR THE 2,925
PRACTICE GROUP OF THE PLAN MEMBER'S PHYSICIAN; 2,926
(c) THE HEALTH CARE FACILITY AT WHICH THE RECOMMENDED OR 2,928
REQUESTED THERAPY WOULD BE PROVIDED; 2,929
(d) THE DEVELOPMENT OR MANUFACTURE OF THE PRINCIPAL DRUG, 2,931
DEVICE, PROCEDURE, OR THERAPY INVOLVED IN THE RECOMMENDED OR 2,932
REQUESTED THERAPY. HOWEVER, EXPERTS AFFILIATED WITH ACADEMIC 2,934
MEDICAL CENTERS WHO PROVIDE HEALTH CARE SERVICES TO MEMBERS OF 2,935
THE PLAN MAY SERVE AS EXPERTS ON THE REVIEW PANEL. FURTHER, 2,936
EXPERTS WITH STAFF PRIVILEGES AT A HEALTH CARE FACILITY THAT 2,937
PROVIDES HEALTH CARE SERVICES TO MEMBERS OF THE PLAN, AS WELL AS 2,938
EXPERTS WHO HAVE A CONTRACTUAL RELATIONSHIP WITH THE PLAN, BUT 2,939
WHO WERE NOT INVOLVED WITH THE PLAN'S DENIAL OF COVERAGE FOR THE 2,941
THERAPY UNDER REVIEW, MAY SERVE AS EXPERTS ON THE REVIEW PANEL. 2,942
THESE NONAFFILIATION PROVISIONS DO NOT PRECLUDE A PLAN FROM 2,943
PAYING FOR THE EXPERTS' REVIEW, AS SPECIFIED IN DIVISION (C)(5) 2,944
OF THIS SECTION.
(5) PLAN MEMBERS SHALL NOT BE REQUIRED TO PAY FOR ANY PART 2,946
OF THE COST OF THE REVIEW. THE COST OF THE REVIEW SHALL BE BORNE 2,947
BY THE PLAN. 2,948
(6) THE PLAN SHALL PROVIDE TO THE INDEPENDENT REVIEW 2,950
ORGANIZATION ARRANGING FOR THE EXPERTS' REVIEW A COPY OF THOSE 2,951
RECORDS IN THE PLAN'S POSSESSION THAT ARE RELEVANT TO THE PLAN 2,952
MEMBER'S MEDICAL CONDITION AND THE REVIEW. THE RECORDS SHALL BE 2,953
DISCLOSED SOLELY TO THE EXPERT REVIEWERS AND SHALL BE USED SOLELY 2,954
FOR THE PURPOSE OF THIS SECTION. AT THE REQUEST OF THE EXPERT 2,955
REVIEWERS, THE PLAN OR THE PHYSICIAN REQUESTING THE THERAPY SHALL 2,956
PROVIDE ANY ADDITIONAL INFORMATION THAT THE EXPERT REVIEWERS 2,957
REQUEST TO COMPLETE THE REVIEW. AN EXPERT REVIEWER IS NOT 2,958
REQUIRED TO RENDER AN OPINION IF THE REVIEWER HAS NOT RECEIVED 2,959
ANY REQUESTED INFORMATION THAT THE REVIEWER CONSIDERS NECESSARY 2,960
TO COMPLETE THE REVIEW.
(7)(a) IN THE CASE OF AN EXPEDITED REVIEW, THE INDEPENDENT 2,962
REVIEW ORGANIZATION SHALL ISSUE A WRITTEN DECISION NOT LATER THAN 2,963
66
SEVEN DAYS AFTER THE FILING OF THE REQUEST FOR REVIEW. IN ALL 2,965
OTHER CASES, THE INDEPENDENT REVIEW ORGANIZATION SHALL ISSUE A
WRITTEN DECISION NOT LATER THAN THIRTY DAYS AFTER THE FILING OF 2,968
THE REQUEST. THE INDEPENDENT REVIEW ORGANIZATION SHALL SEND A 2,969
COPY OF ITS DECISION TO THE PLAN AND THE PLAN MEMBER. IF THE
PLAN MEMBER'S PROVIDER OR THE HEALTH CARE FACILITY RENDERING 2,971
HEALTH CARE SERVICES TO THE PLAN MEMBER REQUESTED THE REVIEW, THE 2,972
INDEPENDENT REVIEW ORGANIZATION SHALL ALSO SEND A COPY OF ITS 2,975
DECISION TO THE PLAN MEMBER'S PROVIDER OR THE HEALTH CARE
FACILITY. 2,976
(b) IN CONDUCTING THE REVIEW, THE EXPERTS ON THE PANEL 2,978
SHALL TAKE INTO ACCOUNT ALL OF THE FOLLOWING: 2,979
(i) INFORMATION SUBMITTED BY THE PLAN, THE PLAN MEMBER, 2,982
AND THE PLAN MEMBER'S PHYSICIAN, INCLUDING THE PLAN MEMBER'S
MEDICAL RECORDS AND THE STANDARDS, CRITERIA, AND CLINICAL 2,984
RATIONALE USED BY THE PLAN TO REACH ITS COVERAGE DECISION; 2,985
(ii) FINDINGS, STUDIES, RESEARCH, AND OTHER RELEVANT 2,987
DOCUMENTS OF GOVERNMENT AGENCIES AND NATIONALLY RECOGNIZED 2,988
ORGANIZATIONS;
(iii) RELEVANT FINDINGS IN PEER-REVIEWED MEDICAL OR 2,990
SCIENTIFIC LITERATURE AND PUBLISHED OPINIONS OF NATIONALLY 2,991
RECOGNIZED MEDICAL EXPERTS; 2,992
(iv) CLINICAL GUIDELINES ADOPTED BY RELEVANT NATIONAL 2,994
MEDICAL SOCIETIES; 2,995
(v) SAFETY, EFFICACY, APPROPRIATENESS, AND COST 2,997
EFFECTIVENESS.
(8) EACH EXPERT ON THE PANEL SHALL PROVIDE THE INDEPENDENT 2,999
REVIEW ORGANIZATION WITH A PROFESSIONAL OPINION AS TO WHETHER 3,000
THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE THAT THE RECOMMENDED 3,001
OR REQUESTED THERAPY IS LIKELY TO BE MORE BENEFICIAL TO THE PLAN 3,002
MEMBER THAN STANDARD THERAPIES. 3,003
(9) EACH EXPERT'S OPINION SHALL BE PRESENTED IN WRITTEN 3,005
FORM AND SHALL INCLUDE THE FOLLOWING INFORMATION: 3,006
(a) A DESCRIPTION OF THE PLAN MEMBER'S CONDITION; 3,008
67
(b) A DESCRIPTION OF THE INDICATORS RELEVANT TO 3,010
DETERMINING WHETHER THERE IS SUFFICIENT EVIDENCE TO DEMONSTRATE 3,011
THAT THE RECOMMENDED OR REQUESTED THERAPY IS MORE LIKELY THAN NOT 3,012
TO BE MORE BENEFICIAL TO THE PLAN MEMBER THAN STANDARD THERAPIES; 3,013
(c) A DESCRIPTION AND ANALYSIS OF ANY RELEVANT FINDINGS 3,015
PUBLISHED IN PEER-REVIEWED MEDICAL OR SCIENTIFIC LITERATURE OR 3,017
THE PUBLISHED OPINIONS OF MEDICAL EXPERTS OR SPECIALTY SOCIETIES; 3,019
(d) A DESCRIPTION OF THE PLAN MEMBER'S SUITABILITY TO 3,021
RECEIVE THE RECOMMENDED OR REQUESTED THERAPY ACCORDING TO A 3,022
TREATMENT PROTOCOL IN A CLINICAL TRIAL, IF APPLICABLE. 3,024
(10) THE INDEPENDENT REVIEW ORGANIZATION SHALL PROVIDE THE 3,026
PLAN WITH THE OPINIONS OF THE EXPERTS. THE PLAN SHALL MAKE THE 3,027
EXPERTS' OPINIONS AVAILABLE TO THE PLAN MEMBER AND THE PLAN 3,028
MEMBER'S PHYSICIAN, UPON REQUEST. 3,030
(11) THE OPINION OF THE MAJORITY OF THE EXPERTS ON THE 3,032
PANEL, RENDERED PURSUANT TO DIVISION (C)(8) OF THIS SECTION, IS 3,033
BINDING ON THE PLAN WITH RESPECT TO THAT PLAN MEMBER. IF THE 3,034
OPINIONS OF THE EXPERTS ON THE PANEL ARE EVENLY DIVIDED AS TO 3,036
WHETHER THE THERAPY SHOULD BE COVERED, THE PLAN'S FINAL DECISION 3,037
SHALL BE IN FAVOR OF COVERAGE. IF LESS THAN A MAJORITY OF THE 3,038
EXPERTS ON THE PANEL RECOMMEND COVERAGE OF THE THERAPY, THE PLAN 3,039
MAY, IN ITS DISCRETION, COVER THE THERAPY. HOWEVER, ANY COVERAGE 3,040
PROVIDED PURSUANT TO DIVISION (C)(11) OF THIS SECTION IS SUBJECT 3,041
TO THE TERMS, LIMITATIONS, AND CONDITIONS OF THE PLAN. 3,042
(12) THE PLAN SHALL HAVE WRITTEN POLICIES DESCRIBING THE 3,044
EXTERNAL REVIEW PROCESS. 3,045
(D) IF A PLAN'S INITIAL DENIAL OF COVERAGE FOR A THERAPY 3,047
RECOMMENDED OR REQUESTED PURSUANT TO DIVISION (A)(3) OF THIS 3,048
SECTION IS BASED UPON AN EXTERNAL REVIEW OF THAT THERAPY MEETING 3,049
THE REQUIREMENTS OF DIVISION (C) OF THIS SECTION, THIS SECTION 3,051
SHALL NOT BE A BASIS FOR REQUIRING A SECOND EXTERNAL REVIEW OF 3,052
THE RECOMMENDED OR REQUESTED THERAPY. 3,053
(E) AT ANY TIME DURING THE EXTERNAL REVIEW PROCESS, THE 3,056
PLAN MAY ELECT TO COVER THE RECOMMENDED OR REQUESTED HEALTH CARE
68
SERVICE AND TERMINATE THE REVIEW. THE PLAN SHALL NOTIFY THE PLAN 3,058
MEMBER AND ALL OTHER PARTIES INVOLVED BY MAIL OR, WITH CONSENT OR 3,059
APPROVAL OF THE PLAN MEMBER, BY ELECTRONIC MEANS. 3,060
(F) THE PLAN SHALL ANNUALLY FILE A CERTIFICATE WITH THE 3,062
SUPERINTENDENT OF INSURANCE CERTIFYING ITS COMPLIANCE WITH THE 3,063
REQUIREMENTS OF THIS SECTION. 3,064
Sec. 3923.78. NOTHING IN SECTIONS 3923.75 TO 3923.79 OF 3,066
THE REVISED CODE SHALL BE CONSTRUED TO CREATE A CAUSE OF ACTION 3,068
AGAINST ANY OF THE FOLLOWING:
(A) AN EMPLOYER THAT PROVIDES HEALTH CARE BENEFITS TO 3,072
EMPLOYEES THROUGH AN INSURER;
(B) A CLINICAL PEER, MEDICAL EXPERT, OR INDEPENDENT REVIEW 3,075
ORGANIZATION THAT PARTICIPATES IN AN EXTERNAL REVIEW UNDER 3,076
SECTION 3923.76 OR 3923.77 OF THE REVISED CODE; 3,077
(C) A PLAN THAT PROVIDES COVERAGE FOR BENEFITS PURSUANT TO 3,081
SECTION 3923.76 OR 3923.77 OF THE REVISED CODE. 3,082
Sec. 3923.79. CONSISTENT WITH THE RULES OF EVIDENCE, A 3,085
WRITTEN DECISION OR OPINION PREPARED BY AN INDEPENDENT REVIEW 3,086
ORGANIZATION UNDER SECTION 3923.76 OR 3923.77 OF THE REVISED CODE 3,087
SHALL BE ADMISSIBLE IN ANY CIVIL ACTION RELATED TO THE COVERAGE 3,088
DECISION THAT WAS THE SUBJECT OF THE DECISION OR OPINION. THE 3,089
INDEPENDENT REVIEW ORGANIZATION'S DECISION OR OPINION SHALL BE 3,090
PRESUMED TO BE A SCIENTIFICALLY VALID AND ACCURATE DESCRIPTION OF 3,091
THE STATE OF MEDICAL KNOWLEDGE AT THE TIME IT WAS WRITTEN. 3,092
CONSISTENT WITH THE RULES OF EVIDENCE, ANY PARTY TO A CIVIL 3,095
ACTION RELATED TO A PLAN'S DECISION INVOLVING AN INVESTIGATIONAL
OR EXPERIMENTAL DRUG, DEVICE, OR TREATMENT MAY INTRODUCE INTO 3,096
EVIDENCE ANY APPLICABLE MEDICARE REIMBURSEMENT STANDARDS 3,097
ESTABLISHED UNDER TITLE XVIII OF THE "SOCIAL SECURITY ACT," 49 3,099
STAT. 620 (1935), 42 U.S.C.A. 301, AS AMENDED. 3,100
Sec. 5747.01. Except as otherwise expressly provided or 3,109
clearly appearing from the context, any term used in this chapter 3,110
has the same meaning as when used in a comparable context in the 3,111
Internal Revenue Code, and all other statutes of the United 3,112
69
States relating to federal income taxes. 3,113
As used in this chapter: 3,115
(A) "Adjusted gross income" or "Ohio adjusted gross 3,117
income" means adjusted gross income as defined and used in the 3,118
Internal Revenue Code, adjusted as provided in divisions (A)(1) 3,120
to (17) of this section:
(1) Add interest or dividends on obligations or securities 3,122
of any state or of any political subdivision or authority of any 3,123
state, other than this state and its subdivisions and 3,124
authorities.
(2) Add interest or dividends on obligations of any 3,126
authority, commission, instrumentality, territory, or possession 3,127
of the United States that are exempt from federal income taxes 3,128
but not from state income taxes. 3,129
(3) Deduct interest or dividends on obligations of the 3,131
United States and its territories and possessions or of any 3,132
authority, commission, or instrumentality of the United States to 3,133
the extent included in federal adjusted gross income but exempt 3,134
from state income taxes under the laws of the United States. 3,135
(4) Deduct disability and survivor's benefits to the 3,137
extent included in federal adjusted gross income. 3,138
(5) Deduct benefits under Title II of the Social Security 3,140
Act and tier 1 railroad retirement benefits to the extent 3,141
included in federal adjusted gross income under section 86 of the 3,142
Internal Revenue Code. 3,143
(6) Add, in the case of a taxpayer who is a beneficiary of 3,145
a trust that makes an accumulation distribution as defined in 3,146
section 665 of the Internal Revenue Code, the portion, if any, of 3,147
such distribution that does not exceed the undistributed net 3,148
income of the trust for the three taxable years preceding the 3,149
taxable year in which the distribution is made. "Undistributed 3,150
net income of a trust" means the taxable income of the trust 3,151
increased by (a)(i) the additions to adjusted gross income 3,152
required under division (A) of this section and (ii) the personal 3,153
70
exemptions allowed to the trust pursuant to section 642(b) of the 3,154
Internal Revenue Code, and decreased by (b)(i) the deductions to 3,155
adjusted gross income required under division (A) of this 3,156
section, (ii) the amount of federal income taxes attributable to 3,157
such income, and (iii) the amount of taxable income that has been 3,158
included in the adjusted gross income of a beneficiary by reason 3,159
of a prior accumulation distribution. Any undistributed net 3,160
income included in the adjusted gross income of a beneficiary 3,161
shall reduce the undistributed net income of the trust commencing 3,162
with the earliest years of the accumulation period. 3,163
(7) Deduct the amount of wages and salaries, if any, not 3,165
otherwise allowable as a deduction but that would have been 3,166
allowable as a deduction in computing federal adjusted gross 3,167
income for the taxable year, had the targeted jobs credit allowed 3,168
and determined under sections 38, 51, and 52 of the Internal 3,169
Revenue Code not been in effect. 3,170
(8) Deduct any interest or interest equivalent on public 3,172
obligations and purchase obligations to the extent included in 3,173
federal adjusted gross income. 3,174
(9) Add any loss or deduct any gain resulting from the 3,176
sale, exchange, or other disposition of public obligations to the 3,177
extent included in federal adjusted gross income. 3,178
(10) Regarding tuition credits purchased under Chapter 3,180
3334. of the Revised Code: 3,181
(a) Deduct the following: 3,183
(i) For credits that as of the end of the taxable year 3,186
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 3,188
amount of income related to the credits, to the extent included 3,189
in federal adjusted gross income;
(ii) For credits that during the taxable year have been 3,192
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 3,193
the total purchase price of the tuition credits refunded over the 3,194
71
amount of refund, to the extent the amount of the excess was not 3,195
deducted in determining federal adjusted gross income;. 3,196
(b) Add the following: 3,198
(i) For credits that as of the end of the taxable year 3,201
have not been refunded pursuant to the termination of a tuition
payment contract under section 3334.10 of the Revised Code, the 3,202
amount of loss related to the credits, to the extent the amount 3,203
of the loss was deducted in determining federal adjusted gross 3,204
income;
(ii) For credits that during the taxable year have been 3,207
refunded pursuant to the termination of a tuition payment
contract under section 3334.10 of the Revised Code, the excess of 3,209
the amount of refund over the purchase price of each tuition 3,210
credit refunded, to the extent not included in federal adjusted 3,211
gross income.
(11)(a) Deduct, in the case of a self-employed individual 3,213
as defined in section 401(c)(1) of the Internal Revenue Code and 3,214
to the extent not otherwise allowable as a deduction OR EXCLUSION 3,215
in computing federal OR OHIO adjusted gross income for the 3,217
taxable year, the amount THE TAXPAYER paid during the taxable 3,219
year for insurance that constitutes medical care INSURANCE AND 3,220
QUALIFIED LONG-TERM CARE INSURANCE for the taxpayer, the 3,221
taxpayer's spouse, and dependents. No deduction FOR MEDICAL CARE 3,223
INSURANCE under division (A)(11) of this section shall be allowed 3,224
EITHER to any taxpayer who is eligible to participate in any 3,225
subsidized health plan maintained by any employer of the taxpayer 3,226
or of the TAXPAYER'S spouse of the taxpayer. No deduction under 3,228
division (A)(11) of this section shall be allowed to the extent 3,230
that the sum of such deduction and any related deduction 3,231
allowable in computing federal adjusted gross income for the 3,232
taxable year exceeds the taxpayer's earned income, within the 3,233
meaning of section 401(c) of the Internal Revenue Code, derived 3,234
by the taxpayer from the trade or business with respect to which 3,235
the plan providing the medical coverage is established., OR TO 3,238
72
ANY TAXPAYER WHO IS ENTITLED TO, OR ON APPLICATION WOULD BE
ENTITLED TO, BENEFITS UNDER PART A OF TITLE XVIII OF THE "SOCIAL 3,240
SECURITY ACT," 49 STAT. 620 (1935), 42 U.S.C. 301, AS AMENDED. 3,241
FOR THE PURPOSES OF DIVISION (A)(11)(a) OF THIS SECTION, 3,242
"SUBSIDIZED HEALTH PLAN" MEANS A HEALTH PLAN FOR WHICH THE 3,244
EMPLOYER PAYS ANY PORTION OF THE PLAN'S COST. THE DEDUCTION 3,245
ALLOWED UNDER DIVISION (A)(11)(a) OF THIS SECTION SHALL BE THE 3,248
NET OF ANY RELATED PREMIUM REFUNDS, RELATED PREMIUM
REIMBURSEMENTS, OR RELATED INSURANCE PREMIUM DIVIDENDS RECEIVED 3,251
DURING THE TAXABLE YEAR. 3,252
(b) DEDUCT, TO THE EXTENT NOT OTHERWISE DEDUCTED OR 3,254
EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED GROSS INCOME 3,255
DURING THE TAXABLE YEAR, THE AMOUNT THE TAXPAYER PAID DURING THE 3,256
TAXABLE YEAR, NOT COMPENSATED FOR BY ANY INSURANCE OR OTHERWISE, 3,257
FOR MEDICAL CARE OF THE TAXPAYER, THE TAXPAYER'S SPOUSE, AND 3,258
DEPENDENTS, TO THE EXTENT THE EXPENSES EXCEED SEVEN AND ONE-HALF 3,259
PER CENT OF THE TAXPAYER'S FEDERAL ADJUSTED GROSS INCOME. 3,260
(c) FOR PURPOSES OF DIVISION (A)(11) OF THIS SECTION, 3,262
"MEDICAL CARE" HAS THE MEANING GIVEN IN SECTION 213 OF THE 3,264
INTERNAL REVENUE CODE, SUBJECT TO THE SPECIAL RULES, LIMITATIONS, 3,265
AND EXCLUSIONS SET FORTH THEREIN, AND "QUALIFIED LONG-TERM CARE" 3,266
HAS THE SAME MEANING GIVEN IN SECTION 7702(B)(b) OF THE INTERNAL 3,267
REVENUE CODE. 3,268
(12)(a) Deduct any amount included in federal adjusted 3,270
gross income solely because the amount represents a reimbursement 3,271
or refund of expenses that in a previous ANY year the taxpayer 3,272
had deducted as an itemized deduction pursuant to section 63 of 3,273
the Internal Revenue Code and applicable United States department 3,275
of the treasury regulations. THE DEDUCTION OTHERWISE ALLOWED 3,276
UNDER DIVISION (A)(12)(a) OF THIS SECTION SHALL BE REDUCED TO THE 3,278
EXTENT THE REIMBURSEMENT IS ATTRIBUTABLE TO AN AMOUNT THE 3,279
TAXPAYER DEDUCTED UNDER THIS SECTION IN ANY TAXABLE YEAR. 3,280
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO ADJUSTED 3,282
GROSS INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT 3,285
73
IS ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 3,287
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO ADJUSTED 3,288
GROSS INCOME IN ANY TAXABLE YEAR.
(13) Deduct any portion of the deduction described in 3,290
section 1341(a)(2) of the Internal Revenue Code, for repaying 3,291
previously reported income received under a claim of right, that 3,292
meets both of the following requirements: 3,293
(a) It is allowable for repayment of an item that was 3,295
included in the taxpayer's adjusted gross income for a prior 3,296
taxable year and did not qualify for a credit under division (A) 3,297
or (B) of section 5747.05 of the Revised Code for that year; 3,298
(b) It does not otherwise reduce the taxpayer's adjusted 3,300
gross income for the current or any other taxable year. 3,301
(14) Deduct an amount equal to the deposits made to, and 3,303
net investment earnings of, a medical savings account during the 3,304
taxable year, in accordance with section 3924.66 of the Revised 3,305
Code. The deduction allowed by division (A)(14) of this section 3,306
does not apply to medical savings account deposits and earnings 3,307
otherwise deducted or excluded for the current or any other 3,308
taxable year from the taxpayer's federal adjusted gross income. 3,309
(15)(a) Add an amount equal to the funds withdrawn from a 3,311
medical savings account during the taxable year, and the net 3,312
investment earnings on those funds, when the funds withdrawn were 3,313
used for any purpose other than to reimburse an account holder 3,314
for, or to pay, eligible medical expenses, in accordance with 3,315
section 3924.66 of the Revised Code;
(b) Add the amounts distributed from a medical savings 3,317
account under division (A)(2) of section 3924.68 of the Revised 3,318
Code during the taxable year. 3,319
(16) Add any amount claimed as a credit under section 3,321
5747.059 of the Revised Code to the extent that such amount 3,322
satisfies either of the following:
(a) The amount was deducted or excluded from the 3,324
computation of the taxpayer's federal adjusted gross income as 3,325
74
required to be reported for the taxpayer's taxable year under the 3,326
Internal Revenue Code;
(b) The amount resulted in a reduction of the taxpayer's 3,328
federal adjusted gross income as required to be reported for any 3,329
of the taxpayer's taxable years under the Internal Revenue Code. 3,330
(17) Deduct the amount contributed by the taxpayer to an 3,332
individual development account program established by a county 3,333
department of human services pursuant to sections 329.11 to 3,334
329.14 of the Revised Code for the purpose of matching funds 3,335
deposited by program participants. On request of the tax 3,336
commissioner, the taxpayer shall provide any information that, in
the tax commissioner's opinion, is necessary to establish the 3,337
amount deducted under division (A)(17) of this section. 3,338
(B) "Business income" means income arising from 3,340
transactions, activities, and sources in the regular course of a 3,341
trade or business and includes income from tangible and 3,342
intangible property if the acquisition, rental, management, and 3,343
disposition of the property constitute integral parts of the 3,344
regular course of a trade or business operation. 3,345
(C) "Nonbusiness income" means all income other than 3,347
business income and may include, but is not limited to, 3,348
compensation, rents and royalties from real or tangible personal 3,349
property, capital gains, interest, dividends and distributions, 3,350
patent or copyright royalties, or lottery winnings, prizes, and 3,351
awards. 3,352
(D) "Compensation" means any form of remuneration paid to 3,354
an employee for personal services. 3,355
(E) "Fiduciary" means a guardian, trustee, executor, 3,357
administrator, receiver, conservator, or any other person acting 3,358
in any fiduciary capacity for any individual, trust, or estate. 3,359
(F) "Fiscal year" means an accounting period of twelve 3,361
months ending on the last day of any month other than December. 3,362
(G) "Individual" means any natural person. 3,364
(H) "Internal Revenue Code" means the "Internal Revenue 3,366
75
Code of 1986," 100 Stat. 2085, 26 U.S.C.A. 1, as amended. 3,367
(I) "Resident" means: 3,369
(1) An individual who is domiciled in this state, subject 3,371
to section 5747.24 of the Revised Code; 3,372
(2) The estate of a decedent who at the time of death was 3,375
domiciled in this state. The domicile tests of section 5747.24 3,376
of the Revised Code and any election under section 5747.25 of the 3,377
Revised Code are not controlling for purposes of division (I)(2) 3,378
of this section.
(J) "Nonresident" means an individual or estate that is 3,380
not a resident. An individual who is a resident for only part of 3,381
a taxable year is a nonresident for the remainder of that taxable 3,382
year. 3,383
(K) "Pass-through entity" has the same meaning as in 3,385
section 5733.04 of the Revised Code. 3,386
(L) "Return" means the notifications and reports required 3,388
to be filed pursuant to this chapter for the purpose of reporting 3,389
the tax due and includes declarations of estimated tax when so 3,390
required. 3,391
(M) "Taxable year" means the calendar year or the 3,393
taxpayer's fiscal year ending during the calendar year, or 3,394
fractional part thereof, upon which the adjusted gross income is 3,395
calculated pursuant to this chapter. 3,396
(N) "Taxpayer" means any person subject to the tax imposed 3,398
by section 5747.02 of the Revised Code or any pass-through entity 3,399
that makes the election under division (D) of section 5747.08 of 3,400
the Revised Code.
(O) "Dependents" means dependents as defined in the 3,402
Internal Revenue Code and as claimed in the taxpayer's federal 3,403
income tax return for the taxable year or which the taxpayer 3,404
would have been permitted to claim had the taxpayer filed a 3,405
federal income tax return. 3,407
(P) "Principal county of employment" means, in the case of 3,409
a nonresident, the county within the state in which a taxpayer 3,410
76
performs services for an employer or, if those services are 3,411
performed in more than one county, the county in which the major 3,412
portion of the services are performed. 3,413
(Q) As used in sections 5747.50 to 5747.55 of the Revised 3,415
Code:
(1) "Subdivision" means any county, municipal corporation, 3,417
park district, or township. 3,418
(2) "Essential local government purposes" includes all 3,420
functions that any subdivision is required by general law to 3,421
exercise, including like functions that are exercised under a 3,422
charter adopted pursuant to the Ohio Constitution. 3,423
(R) "Overpayment" means any amount already paid that 3,425
exceeds the figure determined to be the correct amount of the 3,426
tax. 3,427
(S) "Taxable income" applies to estates only and means 3,429
taxable income as defined and used in the Internal Revenue Code 3,430
adjusted as follows: 3,431
(1) Add interest or dividends on obligations or securities 3,433
of any state or of any political subdivision or authority of any 3,434
state, other than this state and its subdivisions and 3,435
authorities; 3,436
(2) Add interest or dividends on obligations of any 3,438
authority, commission, instrumentality, territory, or possession 3,439
of the United States that are exempt from federal income taxes 3,440
but not from state income taxes; 3,441
(3) Add the amount of personal exemption allowed to the 3,443
estate pursuant to section 642(b) of the Internal Revenue Code; 3,444
(4) Deduct interest or dividends on obligations of the 3,446
United States and its territories and possessions or of any 3,447
authority, commission, or instrumentality of the United States 3,448
that are exempt from state taxes under the laws of the United 3,449
States; 3,450
(5) Deduct the amount of wages and salaries, if any, not 3,452
otherwise allowable as a deduction but that would have been 3,453
77
allowable as a deduction in computing federal taxable income for 3,454
the taxable year, had the targeted jobs credit allowed under 3,455
sections 38, 51, and 52 of the Internal Revenue Code not been in 3,456
effect; 3,457
(6) Deduct any interest or interest equivalent on public 3,459
obligations and purchase obligations to the extent included in 3,460
federal taxable income; 3,461
(7) Add any loss or deduct any gain resulting from sale, 3,463
exchange, or other disposition of public obligations to the 3,464
extent included in federal taxable income; 3,465
(8) Except in the case of the final return of an estate, 3,467
add any amount deducted by the taxpayer on both its Ohio estate 3,468
tax return pursuant to section 5731.14 of the Revised Code, and 3,469
on its federal income tax return in determining either federal 3,470
adjusted gross income or federal taxable income; 3,471
(9)(a) Deduct any amount included in federal taxable 3,473
income solely because the amount represents a reimbursement or 3,474
refund of expenses that in a previous year the decedent had 3,475
deducted as an itemized deduction pursuant to section 63 of the 3,476
Internal Revenue Code and applicable treasury regulations;. THE 3,478
DEDUCTION OTHERWISE ALLOWED UNDER DIVISION (S)(9)(a) OF THIS 3,480
SECTION SHALL BE REDUCED TO THE EXTENT THE REIMBURSEMENT IS
ATTRIBUTABLE TO AN AMOUNT THE TAXPAYER OR DECEDENT DEDUCTED UNDER 3,481
THIS SECTION IN ANY TAXABLE YEAR. 3,482
(b) ADD ANY AMOUNT NOT OTHERWISE INCLUDED IN OHIO TAXABLE 3,485
INCOME FOR ANY TAXABLE YEAR TO THE EXTENT THAT THE AMOUNT IS 3,486
ATTRIBUTABLE TO THE RECOVERY DURING THE TAXABLE YEAR OF ANY 3,487
AMOUNT DEDUCTED OR EXCLUDED IN COMPUTING FEDERAL OR OHIO TAXABLE 3,488
INCOME IN ANY TAXABLE YEAR.
(10) Deduct any portion of the deduction described in 3,490
section 1341(a)(2) of the Internal Revenue Code, for repaying 3,491
previously reported income received under a claim of right, that 3,492
meets both of the following requirements: 3,493
(a) It is allowable for repayment of an item that was 3,495
78
included in the taxpayer's taxable income or the decedent's 3,496
adjusted gross income for a prior taxable year and did not 3,497
qualify for a credit under division (A) or (B) of section 5747.05 3,498
of the Revised Code for that year. 3,499
(b) It does not otherwise reduce the taxpayer's taxable 3,501
income or the decedent's adjusted gross income for the current or 3,502
any other taxable year. 3,503
(11) Add any amount claimed as a credit under section 3,505
5747.059 of the Revised Code to the extent that the amount 3,506
satisfies either of the following: 3,507
(a) The amount was deducted or excluded from the 3,509
computation of the taxpayer's federal taxable income as required 3,510
to be reported for the taxpayer's taxable year under the Internal 3,511
Revenue Code;
(b) The amount resulted in a reduction in the taxpayer's 3,513
federal taxable income as required to be reported for any of the 3,514
taxpayer's taxable years under the Internal Revenue Code. 3,515
(T) "School district income" and "school district income 3,517
tax" have the same meanings as in section 5748.01 of the Revised 3,518
Code. 3,519
(U) As used in divisions (A)(8), (A)(9), (S)(6), and 3,521
(S)(7) of this section, "public obligations," "purchase 3,522
obligations," and "interest or interest equivalent" have the same 3,523
meanings as in section 5709.76 of the Revised Code. 3,524
(V) "Limited liability company" means any limited 3,526
liability company formed under Chapter 1705. of the Revised Code 3,527
or under the laws of any other state. 3,528
(W) "Pass-through entity investor" means any person who, 3,530
during any portion of a taxable year of a pass-through entity, is 3,531
a partner, member, shareholder, or investor in that pass-through 3,532
entity.
(X) "Banking day" has the same meaning as in section 3,534
1304.01 of the Revised Code. 3,535
(Y) "Month" means a calendar month. 3,537
79
(Z) "Quarter" means the first three months, the second 3,539
three months, the third three months, or the last three months of 3,540
the taxpayer's taxable year.
(AA) Any term used in this chapter that is not otherwise 3,542
defined in this section and that is not used in a comparable 3,543
context in the Internal Revenue Code and other statutes of the 3,544
United States relating to federal income taxes has the same 3,545
meaning as in section 5733.40 of the Revised Code. 3,546
Section 2. That existing sections 1751.11, 1751.19, 3,548
1751.33, 1751.35, 1751.77, 1751.78, 1751.81, 1751.82, 1751.83, 3,549
1751.84, 1751.85, 1753.24, and 5747.01 of the Revised Code are 3,550
hereby repealed.
Section 3. Sections 1 and 2 of this act, except for the 3,552
amendment of sections 1751.11, 1751.33, and 5747.01 and the 3,553
enactment of sections 1753.13 and 3923.65 of the Revised Code, 3,554
shall take effect on May 1, 2000. The enactment of section 3,555
1753.13 and the amendment of sections 1751.11, 1751.33, and 3,556
5747.01 of the Revised Code shall take effect on the effective
date of this section. The enactment of section 3923.65 of the 3,557
Revised Code shall take effect 180 days after the effective date 3,558
of this section.
Section 4. Section 3923.65 of the Revised Code applies 3,560
only to policies issued, issued for delivery, or renewed in this 3,562
state 180 days after the effective date of this section and 3,563
thereafter.
Section 5. The amendment by this act of section 5747.01 of 3,565
the Revised Code applies to taxable years beginning on or after 3,566
January 1, 1999.
Section 6. It is the intent of the General Assembly that 3,568
sections 1751.84, 1751.85, 3923.67, 3923.68, 3923.76, and 3923.77 3,569
of the Revised Code, as enacted or amended by this act, provide 3,570
health insuring corporation enrollees, insureds, and governmental 3,571
plan members with a means for resolving health care coverage 3,573
disputes expeditiously and avoid the need for lengthy and
80
expensive litigation. 3,574
Section 7. This act shall be known as "The Patient 3,576
Protection Act of 1999."